Determinants of Arsenicosis Patients Perception and Social Implications of Arsenic Poisoning through Groundwater in Bangladesh

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1 Int. J. Envron. Res. Publc Health 2010, 7, ; do: /jerph Artcle OPEN ACCESS Internatonal Journal of Envronmental Research and Publc Health ISSN Determnants of Arsencoss Patents Percepton and Socal Implcatons of Arsenc Posonng through Groundwater n Bangladesh M. Mzanur Rahman Sarker Department of Economc Systems Analyss, Insttute of Economc Research, Graduate School of Economcs, Htotsubash Unversty, 2-1 Naka, Kuntach, Tokyo , Japan; E-Mal: ed084002@g.ht-u.ac.jp; or mrs_bd@yahoo.com; Tel.: ; Fax: Receved: 20 August 2010; n revsed form: 23 September 2010 / Accepted: 28 September 2010 / Publshed: 14 October 2010 Abstract: Adverse human health effects rangng from skn lesons to nternal cancers as well as wdespread socal and psychologcal problems caused by arsenc contamnated drnkng water n Bangladesh may be the bggest arsenc calamty n the world. From an arsencoss patents survey, ths paper emprcally analyzes the determnants of arsencoss patents percepton about chronc arsenc posonng and socal and psychologcal mplcatons of arsencoss. In ths study, cross-sectonal data were collected from the Matlab and Hajganj Upzllas of Chandpur dstrct whch are known to be hghly contamnated wth arsenc n ther underground water. Respondents nformed that arsenc posonng causes a wde range of socal and psychologcal problems. Female respondents were less vulnerable n the case of socal problems (p < 0.01) and more vulnerable for the psychologcal problems (p < 0.001) of arsencoss than male respondents. The results based on logt analyss showed that educaton (p < 0.01) and household ncome (p < 0.05) were sgnfcantly correlated to respondents percepton about arsencoss. The arsencoss related specal program (s) needs a clear understandng of people s percepton about arsenc exposure for abatng the health burden as well as socal and psychologcal problems. Keywords: logt model; socal mplcaton; percepton; arsencoss; Bangladesh

2 Int. J. Envron. Res. Publc Health 2010, Introducton Arsenc contamnaton of drnkng water s one of the great concerns for publc health throughout the world. Accordng to the Internatonal Agency for Research on Cancer [1] around 100 mllon people n the world, ncludng about 13 mllon n the Unted States, are chroncally exposed to norganc arsenc. Although >20 countres have been affected by arsenc contamnaton of drnkng water, the stuaton s perhaps the most devastatng n Bangladesh because of the number of affected people [2]. Natonwde, 6,528 people wll de from cancer every year and a total of 326,400 people n a perod of 50 years and around 2.5 mllon people wll develop keratoses, hyperpgmentaton, cough, chest sounds, breathlessness, weakness glucosura and hgh blood pressure over that perod [3]. Systematc survey throughout the country by the Department of Publc Health Engneerng (DPHE) and the Brtsh Geologcal Survey (BGS) have estmated that nearly 21 mllon people of about 47 dstrcts are drnkng arsenc contamnated ground water [4] whch s well above the standard lmt of 0.05 mg/l of Bangladesh (the WHO gude lne value s 0.01 mg/l [5]). Securng arsenc-free ground-water has been techncally problematc n many parts of Bangladesh [6-8]. A varety of state agences and NGOs are searchng for optmum mtgaton strateges, n order to reduce the rsk from drnkng posoned groundwater [9]. Arsenc patents may not feel ll or look ll, other than some skn pgment dscoloraton, but they are strpped of ther status n socety and adopt a vrtual dentty as dangerous people [10]. Chronc arsenc exposure s assocated wth many human health condtons, ncludng skn lesons and cancers of the lver, lung, bladder and skn [11-13] as well as other noncancer health effects such as adverse reproductve outcomes, neurologcal dsorders and mpared cogntve development n chldren [14-17]. Arsenc contamnaton has a profound mpact at both the ndvdual and communty levels. Reports have attrbuted dsease and death caused by arsenc toxcty to lack of knowledge about the source of ths metal [18]. Fear of contagousness has separated famles, created socal solaton n schools and led to avodance of people lvng n hghly contamnated regons [19]. Therefore, t s mportant to dentfy the determnants of the patents percepton about arsencoss and to examne the gender dfferences of socal and psychologcal sufferngs from chronc arsenc posonng for reducng the dsease burden and avodable deaths. The present study explores the arsencoss patents percepton and problems by examnng four specfc questons. Frst, what s the soco-economc condtons of arsencoss sufferers? Second, what s the major problems of arsencoss sufferers n case of chld development, gettng marrage and marred lfe? Thrd, do substantal gender dfferences exst n the percepton of socal and psychologal mplcatons of arsenocoss? Fnally, how do the dfferent determnants assocate wth arsencoss patents percepton? 2. Materal and Methods 2.1. Study Area Two Upazlas namely Hajganj and Matlab out of seven Upazlas of Chandpur dstrct were selected as they are known to be hghly contamnated wth arsenc n the underground water and located n southern regon of Bangladesh. The upazla s the second lowest ter of admnstratve government n Bangladesh. The dstrcts of Bangladesh are dvded nto sub-dstrcts called Upazlas. At present,

3 Int. J. Envron. Res. Publc Health 2010, there are 482 upazlas n Bangladesh.The Brtsh Geologcal Survey [4] reported that there s hgh prevalence of arsenc n tube well water n southeast and southern Bangladesh. The melanoss, leucomalanoss and keratoss symptoms were dentfed around 11%, 2% and 2% of the respondents, respectvely n the Hajganj [20]. It s characterzed by densely populated area and agraran economy producng prncpally rce, wheat, vegetables, jute, fsh, mlk and poultry Data Collecton The study s based on prmary data. Feld survey, ntervew, communcaton and nteracton wth dfferent stakeholders were conducted for prmary data collecton. A three-stage samplng procedure was undertaken. Frstly, two Upazlas were selected purposvely. Secondly, prelmnary nformaton about the patents has been collected from the department of publc health engneerng, local NGOs personnel, health workers, famly plannng workers, extenson personnel and ICDDR, B feld workers, and thrdly, then 150 (90 female and 60 male) respondents were selected from 458 patents for the present study. Sample respondents were selected by usng smple random samplng frame work. The female respondents were more than male respondents because the response rate was hgher for female respondents than male respondents. The response rate of respondents was 88%. A pre-desgn pre-tested ntervewer made questonnare was used to conduct the survey. Two traned ntervewers (one man and one woman) conducted the survey by face-to-face ntervew. Attenton was gven to the wordng of the questons durng questonnare desgn, so that the respondents found t smple and could understand t easly Varables The soco-economc varables nclude age, sex, famly sze, house hold ncome, occupaton, source of drnkng and cookng water. Famly members were categorzed nto adult male, adult female and chldren (less than 12 years). The hghest level of educatonal attanment was categorzed nto three levels, namely llterate/no educaton, below Secondary School Certfcate (SSC), and Hgher Secondary Certfcate. House-hold ncome was calculated based on respondents self report. Respondents were asked to classfy ther job nto one of fve dfferent occupatons, namely housewfe, agrculture, busness, servce, and others. The source of water was classfed nto fve categores; tube well, pond, ranwater harvest, rver and canal. Socal mplcatons of the chronc arsenc posonng from drnkng ground water was evaluated by askng the queston Do you thnk that the arsencoss s a cause of dslke of other people to partcpate of socal actvtes? The knowledge of respondents regardng the psychologcal mplcatons of the chronc arsenc posonng from drnkng ground water was evaluated by askng ndrect queston. To assess the psychologcal mplcatons of arsencoss, the respondents were asked the queston Do you thnk that the arsencoss s an evl sprt/god s curse/sn/contagous dsease? Percepton regardng the chronc arsenc posonng from drnkng ground water was evaluated by askng whether the respondent had a clear percepton of adverse health effects of arsenc. The respondents were asked the queston Do you thnk that the drnkng of arsenc-contamnated water s a cause of health problems? If the answerer was yes, then agan the respondents were asked the queston about arsenc related dseases, Do you know that the arsenc-contamnated water s a cause of Melanoss, Leucomelanoss, Keratoss, Hyperkeratoss?

4 Int. J. Envron. Res. Publc Health 2010, Those who know the arsenc-contamnated water s a cause of above mentoned dseases, the respondents consder as they have clear percepton about adverse health effect of arsenc-contamnated drnkng water. The dependent varable was valued at one f the respondent has clear percepton about adverse health effect of arsenc-contamnated drnkng water and zero f he/she has no clear percepton Statstcal Analyses Ths study used descrptve statstcs to descrbe the data and logt regresson model to explore the determnants of the respondents percepton about arsenc exposure to human health. All analyses were performed by usng SPSS package Descrptve Statstcs Descrptve analyses nvolved calculatons of frequency dstrbuton, percentage, mean and tabular statstcs for reportng the socoeconomc characterstcs, skn leson, socal and psychologcal mplcatons of arsencoss. Ch-square test was used to fnd out the assocaton between socal and psychologcal mplcaton of arsencoss and gender of respondents Logt Regresson Logt regresson s used for predcton of the probablty of occurrence of an event. Logt regresson allows one to predct a dscrete outcome from a set of varables that may be contnuous, dscrete, dchotomous, or a mx of any of these. Generally, the dependent or response varable s dchotomous, such as presence/absence or success/falure of an event. To determne respondents percepton about arsencoss the followng Logt model was ftted to the emprcal data whch s gven by Gujarat [21]: L P ln X X X X X X P U where: L = 1 f the respondent has clear percepton about arsencoss and 0 otherwse P = the probablty of the respondents clear percepton about arsencoss X 1 = educatonal qualfcaton of the arsencoss patent (year of schoolng) X 2 = household ncome of the arsencoss patent (n Tk. per year) X 3 = age (n years) X 4 = 1 for male respondent X 4 = 0 for female respondent X 5 = 1 for marred respondent X 5 = 0 for unmarred respondent X 6 = duraton of sufferng from arsencoss (n years) 1 to 6 are coeffcents of the respectve explanatory varables.

5 Int. J. Envron. Res. Publc Health 2010, Results 3.1. Soco-Demographc Background The socoeconomc and demographc characterstcs of surveyed arsencoss patents are presented n Table 1. Respondents comprsed 60 males and 90 females. The average age of the respondent was 50 ± 19 years. Mean age ± SD of male and female were 54 ± 15 and 47 ± 21 years, respectvely. The average number of adult male, adult female and chldren per famly were found to be 2.34, 2.52 and 1.12, respectvely. About 52% of respondents had no formal educaton but 46% respondents had prmary and 2% of respondents had secondary and hgher secondary educaton. Agrculture was the man source of ncome and the average monthly ncome of respondent household was 3,874 Tk. (US$ 56.97) per month. The major occupaton of respondents were 57%, 22%, 8%, 6% and 7% for housewfe, agrculture, busness, servce, and others, respectvely. Respondents reported that the man source of drnkng water was tube well. On the other hand, respondents n the study area stated that the majorty (74%) used pond water as a major source for cookng purposes. Table 1. Soco-demographc characterstcs of the surveyed arsencoss patents. Characterstcs Values Average age of the respondent (years) 50 ± 19 Male 54 ±15 Female 47 ± 21 Average famly member (No) 5.97 ± 3.5 Adult male 2.34 ± 2.0 Adult female 2.51 ± 1.5 Chldren 1.12 ± 2.5 Lteracy No educaton 78 (52%) Below S.S.C. 69 (46%) S.S.C. and H.S.C. 3 (2%) Average monthly household ncome (Tk.) 3,874 ± 3,252 Major occupaton of the respondents Agrculture Busness Servce Housewfe Others Source of drnkng water Tube wells Pond Rver Canal Ran water 33 (22%) 12 (8%) 9 (6%) 85 (57%) 7 (11%) 123 (82%) 12 (8%) 13 (9%) 9 (6%) 33 (22%)

6 Int. J. Envron. Res. Publc Health 2010, Characterstcs Source of cookng water Tube wells Ponds Others Table 1. Cont. Values 33 (22%) 111 (74%) 6 (4%) Responsble for water collecton Men 12 (8%) Women 138 (92%) Note: Number of respondents n parentheses, 68 Tk. = 1 $US 3.2. Socal Implcaton of Arsencoss Attempts were made to learn of the feelngs of the arsenc patents regardng partcpaton n ther socal actvtes. A consderable porton of the respondents (32%) reported that ther neghbors dslke the arsenc patents partcpaton n ther socal actvtes Gender Wse Dstrbuton of Percepton of Socal Implcatons Table 2 examnes whether men or women were better nformed about the socal mplcatons of arsencoss. Among the total respondents 37% reported that arsenc exposure had socal mplcatons and 63% reported that arsencoss had no socal mplcatons. When examned aganst gender t was found that more males (57%) thought that arsencoss had a socal mplcaton than females (24%). Table 2. Dstrbuton of respondents by gender and ther percepton on any socal mplcaton of arsenc exposure. Sex of respondent Socal mplcaton of arsencoss Yes No Total Female 22 (24%) 68 (76%) 90 (100%) Male 34 (57%) 26 (43%) 60 (100%) Total 56 (37%) 94 (63%) 150 (100%) Arsenc Posonng and Chld Development Physcal and mental development of a chld n an arsenc-affected famly may be nterrupted because of dfferent reasons. A consderable percentage of respondents (28%) assumed that unhappy famly lfe may hamper psychologcal development of the chldren. The reported reasons for ths were as follows: the chld mght be deprved of love and affecton due to arsenc-related problems of the father and/or mother; chldren mght be neglected socally due to parent s unhealthy condton; father s and/or mother s llness may result n ncreased workload and create physcal and mental pressure on the chldren.

7 Int. J. Envron. Res. Publc Health 2010, Arsencoss Problems for Seekng Marrage Vctms may face a crss n mantanng ther usual emoton, love and affecton wthn ther daly lfe. Women wth arsencoss usually suffer the most n ths regard. A majorty of the respondents (64%) nformed that a grl mght face dffcultes n gettng marred due to arsencoss. The reasons mentoned for facng dffcultes by the grls were as follows: grls look unattractve and less glamorous due to arsenc posonng (41%); nobody lkes to get marred to a grl patent (8%); and a newly marred arsenc-affected grl may act as transmttng superstton (4%). Accordng to 12 per cent of the respondents, men havng arsencoss were not feelng confdent n gettng marred and eght per cent of the respondents thought that men who had sgns of arsenc exposure to the body were dscouraged by ther frends, relatves and neghbors n gettng marred. Fndngs show that men became dsnterested n marryng a grl who had sgns of arsencoss due to varous reasons, e.g., such a grl would cause unhappy famly condton; such a grl would be sexually malfunctoned; arsenc causes consderable physcal damage to a grl; addtonal money wll be requred for treatment of a newly marred woman Problems n Marred Lfe About one thrd of the respondents (32%) mentoned that marred couples who were sufferng from arsenc posonng may face unhappy conjugal or famly lfe. Fndngs show that an unhappy conjugal stuaton mght arse from the followng reasons: anxety and possblty of endng a marrage, physcal dsablty due to arsencoss. About one fourth of the respondents (27%) ndcated that a marrage mght end n dvorce f the wfe suffered from arsencoss. The antcpated reasons were as follows: arsenc problem of a marred women may deterorate the conjugal relatonshp wth her husband (11%); the husband may lose attracton to hs wfe because of hs wfe s deteroratng physcal appearance (4%); the husband's fear of gettng nfected from hs wfe (2%); and superstton (6%) Percepton of Psychologcal Implcatons of Arsencoss Table 3 shows the relatonshp of gender wth the percepton of psychologcal mplcatons of arsencoss. The dstrbuton of the respondents regardng psychologcal mplcatons vared substantally between the sexes. It s evdent that males (53%) were less conversant than females (91%) wth the psychologcal mplcaton of arsencoss. Table 3. Dstrbuton of respondents by gender and ther percepton about psychologcal mplcaton of arsencoss. Sex of respondent Psychologcal mplcaton of arsencoss Yes No Total Female 82 (91%) 08 (09%) 90 (100%) Male 32 (53%) 28 (47%) 60 (100%) Total 114 (77%) 36 (23%) 150 (100%)

8 Int. J. Envron. Res. Publc Health 2010, Logt Analyss for the Respondents Percepton about Arsencoss Logt model was appled to determne the respondents percepton about arsencoss. In ths model the explanatory varables were educaton of respondent, household ncome, age, gender (dummy), martal status (dummy) and duraton of sufferng from arsencoss of respondents. The results of a logt equaton for respondents percepton about arsencoss are presented n Table 4. The logt analyss showed that two varables namely educaton of the patent and household ncome, were statstcally sgnfcant at 1% and 5% level, respectvely. Table 4. Results of the estmated logt equaton of respondents percepton about arsencoss (t statstcs n parentheses). 4. Dscusson Varables Coeffcents Educaton ** (4.362) Income * (2.377) Male respondent (dummy) (1.032) Age (1.482) Respondent s marred (dummy) (.603) Symptoms present longevty (0.321) Intercept ** (9.864) ** sgnfcance at 0.01 probablty level, * sgnfcance at 0.05 probablty level. The present study shows that the average household sze of 5.97 was slghtly hgher than the average 5.3 of Chandpur dstrct [22]. The respondents were also asked the queston Who s responsble for water collecton n your famly? The response was 92% women and 8% men. Ths s consstent wth other fndngs. In rural Bangladesh, domestc water collecton and management s predomnantly undertaken by women and grls, who spend consderable amount of tme and energy under varous condtons on a daly bass to collect drnkng water for ther famles [23]. It s rare for men to partcpate n domestc water collecton [24]. Arsenc posonng causes a wde range of health problems as well as socal and psychologcal sufferngs such as communty refusal, socal dscrmnaton, unhappy conjugal lfe, chld development problems, mental despondency etc. Fndngs show that non-partcpaton n the socal actvtes by the patents was not only the cause of self-restraned partcpaton n the socal actvtes but also there was dslke of other people to partcpate n ther socal actvtes. Some famly members also do not lke to talk and hestate to come close to arsencoss patents. Studes found that socal and economc loss for people n arsenc areas were acute and rapdly worsenng [25]. Arsenc-related weakness and llness

9 Int. J. Envron. Res. Publc Health 2010, causes further economc damage, as people sufferng from arsencoss were ncreasngly unable to work [26]. Most of the arsencoss patents can not afford ther treatment cost whch leads to socal crss and dstress sellng [27]. Men are more actve n socal actvtes than women; ths may possbly be due to cultural dfferences between men and women. Gender dfference was statstcally sgnfcant (p < 0.01). It s consstent wth a prevous study showng that the socal mplcatons of arsencoss for men and women do vary [24]. Besdes health effects, arsencoss also generates problems n socal and daly lfe and dsturbs the marrage system. There are reports of broken marrages and problems n gettng marred. Women afflcted wth skn spots or lesons (the frst vsble symptoms of arsencoss) have been reported to be treated as contagous and often abandoned or dened marrage. In the same vllage, women/grls wth vsble sgns of arsencoss are facng more dffculty n gettng marred compared to men; ncreased dowry s often demanded of the woman/grl s famly [24]. Arsencoss would not only pose a threat for gettng marred but t also creates many problems wthn marred lfe. A study found that 8% females reported that they had been abandoned by ther husbands [28]. Nearly 53% of the women dentfed the bggest problem to be marrageablty ssues and rejecton of women [29]. The arsenc problem s not only a threat to physcal health of vctms but t would also mpact on mental health of sufferers because of false belefs that stll persst, such as arsencoss s an evl sprt or God's curse or a contagous dsease. Gender dfference of psychologcal sufferngs was statstcally sgnfcant (p < 0.001). Sufferngs from water posonng dffer for male and female accordng to socal status and locatons [30-32]. The results ndcate that wth the ncrease n schoolng years and house-hold ncome of the patent, the probablty of the respondents heghtened percepton about arsencoss would be greater. Soco-economc status varables were related to the knowledge of the health problems of arsenc exposure [19]. A prevous study [2] found that people wth hgher soco-economc status (non labor occupaton of the head of the household and better housng) were more aware of the health effects of arsenc. On the other hand, fndngs of other health surveys have shown that awareness s related to knowledge of a correct behavoral or lfestyle modfcaton [33,34], but these studes are not assocated wth percepton of arsencoss. The man strateges should be amed at ensurng the arsenc free water, awareness rasng program(s) and fnally, ncome generatng actvtes for rural poor people. Women should be traned to know about alternatve ways to get arsenc free water. To ensure the partcpaton of the female local leaders, especally female ward members and upazla vce-presdent n the awareness buld up program. False belef, lack of resources and treatment facltes are major barrers n overcomng arsencoss patents problems. There were several lmtatons n ths study. For practcal reasons, 150 sample respondents were selected for analyss. Ths study was based on cross sectonal data. The present study was not adjusted for other rsk factors such as physcal actvty and smokng. The most of the data were collected by usng self reported data whch mght be affected by the dfferental reportng behavor of men and women. It s plausble that both the occurrence of any health problems and ther consequences are worse n less advantage socoeconomc groups, but we were not able to test ths n our data because the sze of our sample dd not allow us to separate the households nto more detaled ncome brackets.

10 Int. J. Envron. Res. Publc Health 2010, Conclusons The current study examned the socal mplcatons of arsenc posonng and ts serousness. The study found that arsencoss has negatve socal and psychologcal mplcatons whch leads to socal dscrmnaton, uncertanty, njustce, human rghts volaton and threats to famly and conjugal lfe. Women were less educated and psychologcally more vulnerable than men. These fndngs suggest that specal educaton/tranng programs may need to target ndvduals wth low ncome and educaton status n order to mprove percepton about consequences of chronc arsenc posonng; ths would be an mportant element for abatng the ncreasng socal crss. Ideally, poltcal commtments and nsttutonal polces are needed to allocate resources to ensure arsenc-free drnkng water. Untl then, a naton-wde large-scale study based on the current survey wll be of hgh utlty to assess the real burden of arsencoss on varous occupatons, soco-economc segments, gender and age groups. In vew of the ncreasng burden of arsencoss ths should be consdered as an essental part of the natonal poverty allevaton and human development strategy of Bangladesh. Acknowledgements The author would lke to thank the Japanese Government for a scholarshp (Monbukagakusho) to allow hgher study and the Bangladesh Agrcultural Unversty Research System for fundng ths research. Kazum Asako of the Insttute of Economc Research, Htotsubash Unversty, Tokyo, Japan, s gratefully acknowledged for hs help and constant gudance. Thanks also are due to Asako semnar members, anonymous referees and partcpants n the Human exposure: Socal and economc mpacts sesson 3B at the Second Internatonal Congress Arsenc n the Envronment (As 2008) held n Valenca, Span and n the Envronment V: Envronment and Health sesson at the 55th North Amercan Meetngs and conference of the Regonal Scence Assocaton Internatonal (2008), held n New York, USA for ther comments on earler drafts of ths paper. References 1. Some Drnkng-Water Dsnfectants and Contamnants, Includng Arsenc; IARC Monographs on the Evaluaton of Carcnogenc Rsks to Human. IARC Monographs: Lyon, France, 2004; Volume 84, pp Parvez, F.; Chen, Y.; Argos, M.; Hussan, A.Z.; Momotaj, H.; Dhar, R.; van Green, A.; Grazano, J.H.; Ahsan, H. Prevalence of arsenc exposure from drnkng water and awareness of ts health rsks n a Bangladesh populaton: Results from a large populaton-based study. Envron. Health Perspect. 2006, 114, Maddson, D.; Catala-Luque, R.; Pearce, D. The Effects of the Arsenc Contamnaton of Groundwater n Bangladesh; Report Prepared for the Envronment Dvson; World Bank: Washngton, DC, USA, 2004.

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13 Int. J. Envron. Res. Publc Health 2010, Eloundou-Enyegue, P.M.; Meekers, D.; Calves, A.E. From awareness to adopton: The effect of AIDS educaton and condom socal marketng on condom use n Tanzana ( ). J. Bosoc. Sc. 2005, 37, Pechulek, H.; Al-Sabbr, A.; Mendoza-Aldana, J. Darrhea and ARI n rural areas of Bangladesh. Southeast Asan J. Trop. Med. Publc Health 2003, 34, by the authors; lcensee MDPI, Basel, Swtzerland. Ths artcle s an open access artcle dstrbuted under the terms and condtons of the Creatve Commons Attrbuton lcense (