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Interlacing Water and Human Health

ii Interlacing Water and Human Health

Series EditorPeter P. Mollinga, ZEF, Bonn, Germany

Editorial Board Imtiaz Ahmed, Dhaka University, BangladeshN.K. Ambujam, CWR, Chennai, IndiaJayanta Bandyopadhyay, IIM, Kolkata, IndiaN.D.K. Dayawansa, DAE, Peradeniya, Sri LankaAjaya Dixit, NWCF, Kathmandu, NepalNimal Gunawardena, CB, Hyderabad, India(PGIA, Peradeniya, Sri Lanka)S. Janakarajan, MIDS, Chennai, IndiaN.C. Narayanan, CB, Hyderabad, IndiaSmita Mishra Panda, IRMA, Anand, IndiaRezaur Rahman, IWFM/BUET, Dhaka, BangladeshAtiq Rahman, BCAS, Dhaka, BangladeshLinden Vincent, IWE, Wageningen University, The Netherlands

Interlacing Water and Human HealthCase Studies from South Asia

Water in South Asia Volume 3

Editors

Anjal PrakashSaravanan V.S.Jayati Chourey

SaciWATERs

Copyright © SaciWATERs, 2011

All rights reserved. No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage or retrieval system, without permission in writing from the publisher.

First published in 2011 by

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ISBN: 978-81-321-0725-5 (HB)

The SAGE Team: Elina Majumdar, P.K. Jayanthan,

Table of Contents

Series Editor’s Note ixList of Tables xiList of Figures xviiList of Maps xixList of Abbreviations xxiAcknowledgements xxvii

PART I Backdrop

1. Interlacing Water and Health in South Asia:The Problématique 1 Anjal Prakash, Saravanan V.S. and Jayati Chourey

2. Good Evidences, Bad Linkages: A Review of Waterand Health in South Asia 21

Jayati Chourey and Anjal Prakash

3. Water, Health and Poverty in South Asia:Examining the Interface in India 49

Amita Shah and Sajitha O.G.

PART II Water Supply, Sanitation and Human Health

4. Madhya Pradesh’s Complex Challenges: Undernutritionand Infectious Diseases 73

Biraj Swain

5. Inequalities in Access to Safe Drinking Water, Sanitationand Childhood Undernutrition in India 94

William Joe and Udaya Shankar Mishra

6. Access to Safe Water and Health: Mortality,Morbidity and Malnutrition in Nepal 115

Annette L Fitzpatrick, Meera Kansakar, Jason Soh, Pam Elardo, Kevin C. Fitzpatrick and Dibya R. Kansakar

vi Interlacing Water and Human Health

7. Disease Burden Linked to IncompleteWater and Sanitation coverage in Orissa, India 137

Aidan A. Cronin and Srihari Dutta

Part III Intensifi cation of Agriculture, Water and Health

8. Arsenic Contamination, Toxicity and Health Effects:Cases from India and Bangladesh 159

Nalini Sankararamakrishnan and Leela Iyengar

9. Arsenic Pollution and Reproductive Health: A Case Study of Murshidabad District in West Bengal 180

Mohua Guha and Kamla Gupta

10. Water Quality and Human Health in Mewat:Challenges and Innovative Solutions 200

Lalit Mohan Sharma, Aravinda Satyavada andArchana Chowdhury

Part IV Rapid Industrialisation, Water and Health

11. Wastewater use in Vegetable Production and Its Health Impacts: A Case of Faisalabad, Pakistan 233

Abedullah, Shahzad Kouser and Faisal Abbas

12. Role of Farmers in Protecting Groundwater inLower Bhavani River Basin of Tamil Nadu, India 258

Sacchidananda Mukherjee

13. Industrial Water Pollution and Health Implications:Emerging Issues from Tiruppur, Textile Town ofSouth India 287

Prakash Nelliyat

14. Impact of Mining on Water and Human Health: A Case Study of Baitarani River Ecosystem in Orissa 311

Sarmistha Pattanaik

Contents vii

Part V Increasing Urbanisation and Water and Health

15. Wastewater in Sri Lanka: Implications onHuman Health 335

Mohamed Mujithaba, Mohamed Najim andIndika Harshani Rajapakshe

16. Neglected Frontiers: Peri-urban Water Use and Human Health in the National Capital Region, India 360

Vishal Narain

17. Results of Unplanned Programmes: DrinkingWater and Sanitation System in Bhaktapur, Nepal 381

Prachanda Pradhan

PART VI Natural Disasters, Water and Health

18. Inter-relation between Water, Health and Livelihoodin Disasters 405

Papreen Nahar, Fariba Alamgir, Andrew E. Collins,Nibedita Ray-Bennett and Abbas Bhuiya

19. Health Disasters: Tsunami-induced PublicHealth Crisis in India 425

Nibanupudi Hari Krishna and Parnasri Ray Chodhury

Glossary 442About the Editors and Contributors 445Index 00

viii Interlacing Water and Human Health

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Series Editor’s Note

Water and Human Health: Concerns, Perspectives and Case Studies from South Asia is the third volume in the Water in South Asia Series published by SAGE, New Delhi in collaboration with SaciWATERs, The South Asia Consortium for Interdisciplinary Water Resources Studies. Water in South Asia is a series of readers on topical issues on water resources in the South Asia region. The volumes are generated through the Crossing Boundaries: Regional Capacity Building on IWRM and Gender and Water in South Asia project, which seeks to strengthen or establish new Masters programmes in education on water resources management. These new programmes have a broader scope than the conventional technical focus of water resources education, and incorporate concerns like ecological sustainability, equity and poverty, gender relations and democratic governance into professional water education. This reconfi guration of professional water education is supported by a series of training, research and networking activities, of which the production of a series of readers is an important one.

The Crossing Boundaries project is implemented with fi nancial support from the government of the Netherlands. The coordinating South Asian partner is SaciWATERs based in Hyderabad, India. The South Asian University partners are: The Centre for Water Resources, Anna University, India; The Tata Institute of Social Sciences, Mumbai, India; the Institute of Water and Flood Management, Bangladesh University of Engineering and Technology, Dhaka, Bangladesh;Bangladesh Centre for Advance Studies, Dhaka, Bangladesh; the Nepal Engineering College in Kathmandu, Nepal and the Post-Graduate Institute of Agriculture, Peradeniya University, Sri Lanka. The eighth partner is the Irrigation and Water Engineering Group, Centre for Water and Climate, Wageningen University and Research Centre, The Netherlands. The project began in 2005 and will end in 2011.

The Series is a collective product of the project partners, with each volume being edited by two or three editors, and comprising con-tributions from several South Asian countries. The focus is on com-parison at South Asia level, and addressing of regional South Asia

x Interlacing Water and Human Health

water issues is the hallmark of the series. The series seeks to provide a collection of high quality state-of-the-art material on different water resources topics and policy and research agendas that need to be addressed, which is made accessible to a broad spectrum of interested audience, and is suitable as resource material in education and other forms of capacity building.

This volume, third in the series, challenges approaches in which water and health are treated from a sectoral and non-comprehensive perspective. As an alternative, it proposes an integrated and adaptive perspective that combines curative and preventive aspects of water and health. The book comprehensively attempts to understand the signifi cance of environmental and human health related risk and their inter-linkage for a sustainable future, a future that is decided by multi-ple actors in given socio-ecological conditions. To understand water and health dynamics, an interdisciplinary methodology is required, which the chapters in this book outline and advocate. An attempt is made to provide innovative and analytical tools to understand and model water and health complexity, and to highlight the differential roles of a diverse set of factors infl uencing human health. The inter-disciplinary facet of water and health is under-researched. This book hopes to contribute to the development of a wider angle.

Peter P. MollingaProfessor, Department of Development Studies,

School of Oriental and African Studies,University of London, UK

24 January 2011

List of Tables

2.1 Water and Sanitation Coverage in South AsianCountries, 2006 24

2.2 Percentage of Additional Population GainedCoverage between 1990 and 2006 with Respectto Median Population, 1998 25

2.3a. Deaths Attributable to Water, Sanitation and Hygienein 2002 28

2.3b DALYs Attributable to Water, Sanitation and Hygienein 2002 30

3.1 Profi le of Poverty, Health and Water in India 54 3.2 Percentage with Low Body Mass Index (BMI)

and Anaemia for Women and Men in the Age Group 15–49 with Background Characteristics, India 2005–06 58

3.3 Quality of Water Used by Income Groups 593.4 Impact of Different Water Purifi cation Methods

on WRM across Wealth Quintiles 623.5 Evolution of Drinking Water Supply Policies in India 64

4.1 Malnutrition Deaths and their Medical Causes 804.2 Water and Sanitation Status of Khalwa Block,

Khandwa District 824.3 Causes of Child Deaths in Satna 844.4 Health Determinant Status of Majhgawan and

Unchehera Blocks, Satna District 86

5.1 Unsafe Water, Sanitation and Underweight Children (in %) and Inequalities in 18 States of India (2005–06) 104

5.2 Underweight Children According to Maternal Education and WSH Conditions 109

6.1 Trends in Water Access, Sanitation and HealthParameters in Nepal (1990–2006) 118

xii Interlacing Water and Human Health

6.2 Progress and Targets for Health during the10th Plan Period 121

6.3 Access to Water and Latrines in the Study Area 1236.4 Deaths Occurred from 1999–2004 in Mujeliya and

Rajual villages, Janakpur Municipality, Nepal with total population 1,781 127

6.5 Causes of Deaths Reported by Heads of Households in Mujeliya and Rajual Villages Between 1999 and 2004 128

6.6 Rates of Reported Diseases per 1,000 Person-years(Recurrent Episodes Included) 129

7.1 Extent of Mortality Associated with Poor Water andSanitation Provision in India in 2002 139

7.2 Extent of Morbidity Associated with Poor Water andSanitation Provision in India in 2002 139

7.3 Key Statistics on Orissa: Population Figures fromCensus of India (2001) 141

7.4 Total Diarrhoea Cases and Deaths (2002–07) with the Attributable Estimate Due to Poor Water and Sanitation Provision 145

7.5 Total Malaria Cases and Deaths (2004–07) withthe attributable Estimate due to Poor Water andSanitation Provision 146

7.6 Diarrhoea DALYs in India and Orissa, 2002 148

8.1 Statistics of Arsenic Calamity in the Indo–Gangetic Region 1618.2 Chronology of Arsenic poisoning in GMB, India 1628.3 Arsenic in Rock and Sediment 1628.4 Case Studies on Skin Lesions 1648.5 Case Study on Lung Cancer in Bangladesh 1668.6 Case study on Memory and Intellectual Function

in West Bengal, India 1678.7 Case Study on the Bronchiectasis Effect of Arsenic

in West Bengal, India 168

9.1 Comparable Variables among the Exposed andNon-exposed Groups 191

Contents xiii

9.2 Respondents by Mean Pregnancy Outcomes 192 9.3 Adverse Pregnancy Outcomes per 1,000 Live

Births among the Respondents 192

10.1 Parametres for Saline Water (in ppm) 201 10.2 Socio-economic Profi le of Mewat and Haryana 202 10.3 Sources and Likely Consequences of Prolonged

Use of Selected Contaminants 203 10.4 Salinity and Fluoride Affected Districts in Haryana 206 10.5 Chemical Contaminants in Groundwater and

Public Water Supply, 2005 208 10.6 Characteristics of the Sample Households

(Sample Size = 166) 211 10.7 Water and Sanitation Facilities 212 10.8 Hygiene Practices (Sample Size = 166) 213 10.9 Morbidity among School Children of Mewat 21510.10 Comparison of Suitable Technologies for

Karheda’s Water Situation 21710.11 Chemical Contaminants in Groundwater,

Public Water Supply and Recharge Well 225

11.1 Mean Values of Input–Output Quantities per Acre(Freshwater and Wastewater) 240

11.2 Production Function Estimates for Freshwaterand Wastewater per Acre 242

11.3 Cost–Benefi t Analysis for Wastewater and Freshwater Growers (in US$ per acre) 244

11.4 Annual Labour Productivity Loss (monetary terms) in Wastewater and Freshwater Areas 247

11.5 Annual Medical Expenditure Loss in Monetary Terms in Wastewater and Freshwater Areas 250

11.6 Cost–benefi t Analysis Before and After InternalisingCost of Externalities 251

12.1 Groundwater Nitrate-Affected Habitationsacross Indian States 261

12.2 Groundwater Nitrate Pollution in the Studied Villages 270

List of Tables xiii

xiv Interlacing Water and Human Health

12.3 Sample Villages and Basic Sample Characteristics 27312.4 Sources of Drinking Water (in Percentage of

Sample Households) 27412.5 Farmers’ Perceptions about Drinking Water Quality 27512.6 Farmers’ Water Purifi cation Practices (in Percentage

of Total Number of Sample Households) 278

13.1 Chemicals Used in Various Processing Stages in Textile Industry and its Health Risks 300

14.1 The Mining Districts in Orissa: HumanDevelopment Indicators 320

14.2 Land Use Changes in Keonjhar Sadar Block 32214.3 Defi nitions of Mine Exposure, Water, Forest

and Health Impact Variables 32414.4 Sample Villages Surveyed in Keonjhar District 32514.5 Percentage of Responses on Mine Exposure

and Environment 32614.6 Responses on employment, income, health impact

and physical displacement 328

15.1 Proposed Confi gurations for the Disposal of Septic Tank Effl uents for Sri Lankan Conditions 339

15.2 Recommended Minimum Distances Between aDug Well and Source of Faecal Contamination 340

16.1 Categories of Housing Stock in Delhi 36416.2 Relationship Between Type of Settlement, Tenure,

Poverty and Access to Individual Water SupplyConnection 366

17.1 Water-borne Diseases Treated in BhaktapurHospital, Bhaktapur 390

17.2 Key Features of the Wastewater Treatment Plants inBhaktapur 391

17.3 Interventions by GoN to Achieve MDGs 39517.4 National Standard of Water Quality 396

18.1 Agriculture, Environmental Hazard and Illness inthe Study Areas 413

19.1 Incidence of Communicable Diseases Due to Floods 42919.2 Probable Indicators for Effective Emergency

Public Health Promotion 43119.3 Phase-wise Impact of Tsunami on Water Resources 432

List of Tables xv

xvi Interlacing Water and Human Health

Contents xvii

List of Figures

2.1 A Framework for Good Governance for IntegratingWater and Health (Based on Eight Characteristicsof Good Governance Defi ned by UNESCAP) 43

3.1 Percentage of Population Reporting Morbidityby Monthly Per Capita Consumption Expenditure 57

3.2 Anaemia among Women and Men in the Age Group15–49 by the Type of Drinking Water 60

5.1 Framework of WSH, Child Undernutritionand Health Inequalities 98

5.2 Prevalence Rate of Underweight by Wealth Quintiles,Disaggregated by Sex 102

5.3 Concentration Curves for Inadequate Water, Sanitationand Underweight Children 106

6.1 Number of Family Members Evaluated for Health Status among Mujelia and Rajaul Communities 123

6.2 Z-score Distributions of Height-for-Age inChildren Aged 12 and below Compared toStandardised Data of WHO 129

6.3 Z-score Distributions of Weight-for-Age in ChildrenAged 12 and below Compared to StandardisedData of WHO 130

6.4 Z-score Distributions of Weight-for-Height inChildren aged 12 and below Compared to StandardizedData of WHO 130

6.5 Percentage of Children Malnourished, Stunted, or atRisk for Developmental Problems Due to Lack of Nutrition in Two Communities of Rural Nepal 131

7.1 Infant Mortality Rates during 1990–2007 forIndia and Orissa 141

7.2 Evolution of Severe Diarrhoea Cases in OrissaDistricts 2002–06 148

xviii Interlacing Water and Human Health

7.3 Annual Parasite Index (API) During 2004 to 2007Versus Sanitation Coverage (%) in the 30 Districtsof Orissa in 2007 149

10.1 Groundwater Quality in Haryana 20510.2 Location of Karheda in Mewat District, Haryana 20710.3 Advancing Saline and Shrinking Fresh

Groundwater Pockets 21010.4 Spread of Fresh Harvested Rain Water

under the Ground 21910.5 Innovative Model of RWH in Karheda 22010.6 Bio-sand Filter 222

11.1 Different Sources of Urban Wastewater 234

13.1 Location of Textile Processing Units in Tiruppur Area 29313.2 Knitwear Garment Export Value from Tiruppur 29413.3 Major Activities in Tiruppur Knitwear Industry 295

14.1 Small Iron Ore Mines in Keonjhar 319

15.1 Surface Water Quality Variation among Different Communities in Terms of Infl ow and Outfl ow Water 342

15.2 Groundwater Contamination in Black Forest Colony,Pussellawa Town and Rothschild Estate Communities 345

15.3 Water-related Diseases Reported at Different PHIAreas from 1996 to 2007 347

15.4 Total Number of Disease Incidents in Alawwa,Kudagalgamuwa, Kurunegala and Narammala Areas 353

15.5 Types of Diseases in Alawwa, Kudagalgamuwa,Kurunegala, and Narammala Areas 354

18.1 Field Site Locations 409

List of Maps

7.1 Location of Orissa State in the East of India (inset) and Demarcation of the 30 Districts in the State 140

7.2 Water, Sanitation, Diarrhoea and MalariaIndicators in Orissa 147

12.1 Location Map of the Lower Bhavani River Basin,Tamil Nadu 264

12.2 Study Villages in the Lower Bhavani River Basin,Tamil Nadu 265

14.1 Physiographic Division of Baitarani Basin 317

15.1 Pussella Oya Catchment 34115.2 Alawwa, Kudagalgamuwa, Kurunegala and

NarammalaPHI areas 346

17.1 Location of Bhaktapur Town 38317.2 Water Supply and Sewerage System of Bhaktapur 386

19.1 Locations of Tsunami-hit Areas 432

xx Interlacing Water and Human Health

List of Abbreviations

AAN Asia Arsenic NetworkACHDw Average Cost of Health Damages or ExternalitiesADB Asian Development BankAEPC Apparel Export Promotion CouncilAF Attributable FractionAIDS Acquired Immune Defi ciency SyndromeAIIH&PH All India Institute of Hygiene and Public HealthANBWE Average Net Benefi t of WastewaterAPI Annual Parasite IndexARI Acute Respiratory InfectionARPs Arsenic Removal PlantsARWSP Accelerated Rural Water Supply ProgrammeAWC Anganwadi CentreAWW Anganwadi WorkerBCC Behavior Change CommunicationBDP Bhaktapur Development ProjectBIS Bureau of Indian StandardsBMI Body Mass IndexBMP Best Management PracticeBOD Biochemical Oxygen DemandCC Concentration CurveCDC Centre for Disease Control and PreventionCDC Community Development CouncilCDR Crude Death RateCEC Central Empowered CommitteeCETP Common Effl uent Treatment PlantCPR Center for Policy ResearchCFR Case Fatality RateCGWB Central Ground Water BoardCI Concentration IndexCMC Colombo Municipal CouncilCOD Chemical Oxygen DemandCP Cleaner Production

xxii Interlacing Water and Human Health

CSE Centre for Science and EnvironmentCSME Centre for Study of Man and EnvironmentDALY Disability Adjusted Life YearDDA Delhi Development AuthorityDDT Dichloro Diphenyl TrichloroethaneDFID Department for International DevelopmentDHAP Decentralised Health Action PlanDHS Demographic and Health SurveyDJB Delhi Jal BoardDMC Delhi Metropolitan CouncilDNA Deoxyribonucleic AciddS/m decisiemens per metreDWCD Department of Women and Child DevelopmentDWSS Department of Water Supply and SanitationEC Electrical ConductivityEIA Environmental Impact AssessmentEMP Environmental Management PlanENN Environmental News NetworkEPL Environmental Protection LicenseFGD Focused Group DiscussionFRC Free Residual ChlorineFS Faecal StreptococciGBD Global Burden of DiseaseGDP Gross Domestic ProductGFA Gross Fixed AssetsGHA Global Humanitarian AssistanceGBM Ganga–Meghana–BrahmaputraGNI Gross National IncomeGoI Government of IndiaGoN Government of NepalGoWB Government of West BengalGSI Geological Survey of IndiaGWP Global Water PartnershipHA Height for AgeHb HaemoglobinHC Head CircumferenceHDI Human Development Index

HDP High Density Polythene pipesHEC Higher Education CommissionHFA Hyogo Framework of ActionHPTW Hand Pumped TubewellHUDA Haryana Urban Development AuthorityIARC International Agency for Research on CancerICDDR International Centre for Diarrhoeal Disease

ResearchICDS Integrated Child Development ServicesICMH International Center for Migration and HealthICRISAT International Crops Research Institute for the

Semi-Arid TropicsIEC Information, Education and CommunicationIETP Individual Effl uent Treatment PlantIFPRI International Food Policy Research InstituteIIPS International Institute of Population SciencesIQ Intelligence QuotientIRB Institutional Review BoardISH Ischemic Heart DiseaseISHI India State Hunger IndexIWRM Integrated Water Resources ManagementJE Japanese EncephalitisJMP Joint Monitoring ProgrammeLBP Lower Bhavani ProjectLEI Living Earth InstituteLPCD Litres Per Capita Per DayMDG Millennium Development GoalMetHb Methaemoglobinmg/L milligram/litremld million litres per dayMNC Multi National CorporationMoRD Ministry of Rural DevelopmentMoU Memorandum of UnderstandingMPCE Monthly Per Capita ExpenditureMSL Mean Sea LevelMT Metric Tonnemt million tones

List of Abbreviations xxiii

xxiv Interlacing Water and Human Health

MUHHDC Mahbub ul Haq Human Development CentreNCT National Capital TerritoryNDMC New Delhi Municipal CorporationNFHS National Family Health SurveyNGO Non-Governmental OrganisationNHS National Habitations SurveyNLPLw Net Labour Productivity LossNMELw Net Medical Expenditure LossNO3 NitrateNOIDA New Okhla Industrial Development AreaNPK Nitrogen, Phosphorus and PotassiumNPS Non-Point SourceNRC Nutrition Rehabilitation CentreNREGA National Rural Employment Guarantee ActNSSO National Sample Survey OrganisationNSWQ National Standard of Water QualityNVBDCP National Vector Borne Disease Control

ProgrammeNWSC Nepal Water Supply CorporationNWSDB National Water Supply and Drainage BoardO&M Operation and MaintenanceOSPCB Orissa State Pollution Control BoardPBMI Prevalence of Body Mass IndexPCP Poly Chloro PhenolPDS Public Distribution SystemPHC Public Health CentrePHED Public Health Engineering DepartmentPHI Public Health InspectorsPOSCO Pohang Steel CompanyPTG Primitive Tribal GroupPUI Peri-Urban InterfaceRGI Registrar General of IndiaRO Reverse OsmosisRTI Right to InformationRWH Roof Water HarvestingRWSSFB Rural Water Supply and Sanitation Fund Board

SANDRP South Asia Network on Dams, Rivers & PeopleSD Standard DeviationSEHD Society for Environment and Human

Development SIHMA South India Hosiery Manufacture AssociationSITRA South India Textile Research AssociationSLSI Sri Lanka Standard InstitutionSLTHP Second Long Term Health PlanSOES School of Environmental StudiesSPSS Statistical Package for Social SciencesSRS Sample Registration SystemSSI Small-Scale IndustrySTM School of Tropical MedicineTC Textile CommitteeTDA Tiruppur Dyers’ AssociationTDS Total Dissolved SolidsTEA Tiruppur Exporters’ AssociationTERI Tata Energy Research InstituteTISCO Tata Iron and Steel Company LimitedTNC Transnational CorporationTNPCB Tamil Nadu Pollution Control BoardTP Town PanchayatTSC Total Sanitation CampaignTSS Total Suspended SolidsTTC Thermo Tolerant ColiformsTWAD Tamil Nadu Water Supply and DrainageUA Urban AgglomerationUN United NationsUNDP United Nations Development ProgrammeUNEP United Nations Environment ProgrammeUNHCR United Nations High Commissioner for RefugeesUNICEF United Nations Children’s FundUNIDO United Nations Industrial Development

OrganisationUSA United States of AmericaUSD United States Dollar

List of Abbreviations xxv

xxvi Interlacing Water and Human Health

VALPL Value of Annual Labour Productivity LossVAMEL Value of Annual Medical Expenditures LossVP Village PanchayatWA Weight for AgeWCDR World Conference on Disaster ReductionWDSC Women Development Service CentreWH weight for HeightWHO World Health OrganizationWII–IWMI Winrock International India–International Water

Management InstituteWSP Water and Sanitation Programme

Acknowledgements

The support and fi nancial grant of the Government of the Netherlandsis gratefully acknowledged in the commissioning of the studies included in this volume. The support extended by the SaciWATERs offi ce staff, particularly Hemalatha Paul and Sumathi Shivam, is pro-foundly acknowledged. All the participants in the Readers Workshop on Water and Health in South Asia need to be mentioned for pro-viding invaluable comments and peer reviewing the papers presented. Discussions at this workshop shaped this book in more than one ways. The editors also acknowledge the support from Malvika Kaul in copy editing this book. The editors are indebted to all those who directly or indirectly facilitated the production of this volume.

xxviii Interlacing Water and Human Health

PART I BACKDROP

2 Anjal Prakash, Saravanan V.S. and Jayati Chourey

1

Interlacing Water and Health in South AsiaThe Problématique

ANJAL PRAKASH, SARAVANAN V.S. AND

JAYATI CHOUREY

HOW ARE WATER and health interlaced and where does the crux lie in conceptual understanding and practical implications? While critically analysing some of the issues associated with the problem of interlinking water and health, this book challenges the popular notion where water and health are treated with sectoral and non-comprehensive approach as against an integrated approach in South Asia. It attempts to offer acomprehensive picture on the risk from water pollution on human health and their inter-linkage for a sustainable future, a future that is decided by multiple actors in a given context and socio-ecological conditions. To understand this process, an interdisciplinary meth-odology is required which this book follows. Further, it is an attempt to provide innovative and analytical tools to understand and model complexity to highlight the differential role of a diverse set of fac-tors infl uencing human health. Unfortunately, much has not been written on the interdisciplinary facet of water and health. This book contributes to this from a much wider angle.

Over 1 billion people lack access to safe water while 2.6 billion people lack adequate sanitation. Inadequate availability of safe drinking water and sanitation has given rise to various diseases, where water acts as a medium for the diseases. Water-associated infectious diseases claim up to 3.2 million lives each year, approximately 6 per cent of all deaths globally. The global burden of disease reveals inadequate availability of water, sanitation and hygiene as one of the major risk factors for global ecological deaths (Ezzati et al. 2002, cited in Eyles and Consitt 2004: 26). The Disability-Adjusted Life Year’s (DALY’s)


estimates reveal that the disease burden from environmental factors are higher in developing countries—27 per cent in Africa and 18 per cent in Asia—which houses most of the world’s poor (Murray and Lopez 1996, in Lvovsky 2001: 3). The burden of disease from inadequate water, sanitation and hygiene totals 1.7 million deaths and the loss of more than 54 million healthy life years. Each day a person needs 20–50 litres of water free from harmful chemical and microbial con-taminants for drinking, cooking and hygiene. The UNDP recognises providing access to safe drinking water and sanitation as ‘the most powerful preventive medicines available to governments to reduce infectious disease. Investment in this area is to killer diseases like diarrhoea, what immunization is to measles – a life saver’ (UNDP 2006: 6). This approach has gained worldwide prominence. Worldwide, development agencies have increased their investment on this powerful preventive medicine to combat water-transmitted diseases to address the Millennium Development Goals (refer Goals 4, 6, and 7). The World Bank has invested almost its entire 5.5 billion USD in rural water and sanitation programmes during 1978–2003 (Iyer et al. 2006). Drawing from case studies in South Asia, this book questions the simplistic prescriptive approach from international agencies. It reveals that water-associated diseases are infl uenced by the global environmental change, which includes changes in the physical and biogeochemical environment, either caused naturally or infl uenced by human activities such as deforestation, fossil fuel consumption, urbanisation, land reclamation, agricultural intensifi cation, freshwaterextraction, fi sheries over-exploitation and waste production, which are driven by complex socio-economic and natural processes (Leemans et al.2009: 1). These changes are ‘global’ in the sense of either being globally integrated (that is entailing a systemic change to a global system such as climate system or globalisation) or occurring by worldwide aggre-gation of widespread local changes (for example, land degradation, urbanisation, or overuse of resources) (Confaloneri and McMichael 2007: 8). Saravanan and Mollinga (2008a) reveal these global–local forces in the form of growing urbanisation, rapid industrialisation, intensifi cation of agricultural practices and growing threat from climate change that have made South Asian countries vulnerable to water-associated diseases.

Interlacing Water and Health in South Asia 5

Urbanisation is a growing concern in Asian countries. India pre-sents a daunting picture. Of the total population of 1.027 billion, about742 million live in rural areas while 285 million reside in urban areas.‘If urban India was considered a separate country, it would be the fourth largest in the world after China, India and the United States’ claims Singh et al (2004: 1). As the cities grow, so do their slum popu-lation. As per the UN Habitat reports (UNHSP 2006), 31 per cent of the total global urban population and 41 per cent of developing world reside in slums. Slums are increasing at a rapid rate in South Asia. Improper housing and inadequate drainage and sanitation cov-erage force many slum dwellers to defecate in the open. This causes contamination of water and land resources within cities and in its periphery, leading to diffused sources of pollution.

The unprecedented urbanisation coupled with rapid industrialisa-tion is exerting pressure on the quality of water resources placing human health at risk. Industry is one of the major consumers of water resources, competing with agriculture in South Asian countries.In India, based on notifi cations from the Central Pollution Control Board (CPCB), iron and steel are the highest water polluters con-tributing 87 per cent of the total water pollution load and also in terms of toxicity (Bhardwaj 2005). Though this industry is followed by others in terms of total water pollution load, in terms of toxic load, leather industry is one of the major players. Leather industry is also one of the major contributors to the exports from India. The situation is not different in neighbouring Asian countries. Although data are scarce, a UNIDO report claims that industrial pollution in Pakistan is increasing at a rapid pace having signifi cant impact on the health and productivity (Aftab et al. 2000). Most of the Pakistani industries are located around major cities, and increasingly pollute the streams, rivers and the Arabian Sea through untreated toxic waste. Major industrial contributors are pulp and paper, chemicals, petrochemicals, tanneries, refi neries, metal works, food processing and textile industries(Khan et al. 2001: 384). Further complicating is the fact that these small-scale industries drive the South Asian economies.

Small-scale industries contribute 40 per cent of industrial produc-tion, 35 per cent of total exports and employ about 17 million people in 3.2 million industrial units in India. Of these, engineering, paper


mills and textiles are the largest wastewater generators (Agarwal 2001).In Pakistan, textile and leather industries form a large part of informal and small-scale sectors. Textile industry contribute 67 per cent of the export earnings and engage 35 per cent of the labour force, while leather industry is the second largest export earning sector (ACU 2006).As on 2003, it contributed US$ 700 million a year, but has the poten-tial to multiply the volume of exports with the improvement of quality and diversifi cation into different ranges of products (Bashar 2003). However, these two are the most polluting industries in Pakistan. The situation is no different for Bangladesh. It has 1,176 units that heavily pollute the environment. Of these pulp and paper, textiles and leather industries are the dominant sources of wastewater pollutants. The growth of these industries is combined with inadequate urban and regional planning, regulation of industrial zoning, inadequate pollution monitoring, in-effective technologies to treat water and poor infrastructure planning to dispose the wastewater and an empowered civil society.

While there is growing concern for adequate provision of water supply and sanitation in South Asian countries, there is equal concern towards addressing wastewater generated by both industrial and do-mestic effl uents affecting human health in urban regions. Wastewater irrigation has been practised in many countries around the world, especially in growing economies, placing its growing population in urban and peri-urban region at risk (Confaloneri et al. 2007, Bogner et al. 2007, UNDP 2006: 39–40 quoted in Saravanan et al. 2010). In Pakistan, water-borne diseases are common as more than 40 per cent of water supplied is unfi ltered and 60 per cent of effl uents remain untreated. In the fi rst half of 2006, major outbreaks of water-borne disease epidemics swept Faisalabad, Lahore, Karachi and Peshawar as a result of leakage of sewage and industrial waste into drinking water through damaged pipes. This led the government to fi nance more than 6,000 water fi ltration plants. In India, with more than 50 per cent of the urban population living in squatters, only about 35 per cent of the wastewater from Class I cities (having population above 100,000) and Class II towns (having population between 50,000 and 100,000) is treated, posing potential hazard to human population (Bhardwaj 2005 quoted in Saravanan et al. 2010). In rural regions of the South


Asian countries intensifi cation of agriculture is emerging as one of the major environmental health disasters. Excess fl uoride, arsenic and nitrate in drinking water and water used for domestic purposes have caused serious public health problems in South Asia and Latin America (Kundzewicz et al. 2007). These are naturally occurring min-erals in rocks, soil, water and biota, which are essential but are toxic when exceeds a threshold level. There are about 20 or more common elements in nature that have been identifi ed as potential hazards to human health. Of these, fl uoride and arsenic are most common, and in recent years nitrate is emerging in many parts of South Asia as a potential hazard.

These problems are aggravated by an emerging threat from climate change in the Asian sub-continent, which is likely to intensify the water-communicated diseases. Hunter (2003) and Ebi (2008) warn of potential negative impacts of climate-related changes, namely in-creased temperature and increased fl ooding of water-borne and vector-borne infections worldwide. This will be aggravated with destructive growth, poverty, political rigidity, dependency and isolation in many Asia–Pacifi c countries (Woodward et al. 1998). The pathway that these threats affect these diseases is not a cause-effect paradigm to be addressed through a simplistic preventive medicine, but is ‘intrinsically complex, entailing perturbations of ecosystems and feedbacks between concurrent environmental change processes’ (Sieswerda et al. 2001 cited in Confaloneri and McMichael 2007: 9), many of which interact with each other and with local–global scale changes making it diffi cult to describe and predict the impact on human health.

A review of literature on water and health (Saravanan et al. 2010, Saravanan and Mollinga 2008b) reveal diverse set of factors interacting temporally and spatially in infl uencing environment-related disease, making it complex for simplistic prescription of single or even multi-ple interventions. These diseases are intricately linked with a number of sub-systems of urbanisation, agricultural activity, food security and human health responding to stimuli in various sub-systems(McMicheal 2001, Lebel 2003). The complexity of diverse envir-onmental factors affects human health in multiple pathways. This interacts with demographic, socio-cultural, economic, and other regional factors differentially impacting on human health and their


environment, which are not completely understood. Often this results in considerable uncertainty in which decisions have to be taken. With incomplete and imperfect understanding of these uncertainties hu-man entities (individuals and organisations) develop strategic action, often resulting in competing claims and demands over freshwater. These contestations are facilitated (or constrained) by socially or insti-tutionally distinct agents, who attempt to bring about change in the existing institutional arrangements and bio-physical environment.1 These changes are not always perfect or effi cient, but demonstrate the ability to self-organise, leading back to complexity. Embracing these properties and understanding their interaction is important given the global dimensions of the water-related health issues, especially in developing countries. The review further reveals a fragmented understanding of the complex relationship between water and health among current academic research. Though these research studies and policy approaches provided ground for curative and, in recent years, calls for a preventive approach from a variety of disciplinary per-spectives, as rightly concluded by McMichael et al. (2006: 580), ‘little research has been done on the indirect pathways that link climate change to resultant social, economic, and demographic disruptions and their knock-on health effects’. Research cutting across disciplines represents ‘an important input to international and national policy debates’ (ibid: 581). This book attempts to capture some of these properties and their interaction through empirical research in different countries in South Asia.

STRUCTURE OF THIS BOOK This book is divided into six sections.

Section I provides an overview of inter-linkages between water and health in South Asia, mapping their status and its link with poverty. Investigating the status of water and health in South Asia, Chourey and Prakash (Chapter 2) inform on millions of people lacking access

1 Bruce Mitchell draws on a similar approach to understand the multifariouslinkage within environment and resource management by appreciating the com-plexity, uncertainty, confl icts and change (Mitchell 1997).


to safe water and sanitation. Although countries seem to have worked on the Millennium Development Goals (MDGs) to create infrastructure for water supply and sanitation, it is still questionable whether these measures have led to increased access to adequate safe water and proper sanitation for all. The preventable water-borne diseases contribute to the top ten causes of death in the region. Mortality due to these dis-eases has decreased in the past ten years, but morbidity is on the rise.Diarrhoea remains a primary cause for majority of deaths in South Asia. Besides infectious diseases, chemical contamination of surface and ground water also create a great threat. Arsenic and fl uoride contam-ination are emerging challenges to public health. Although countries have progressed in controlling water-borne diseases yet achievements have been limited. The authors opine that the relationship between water and health is not linear, and is governed by various interlinked socioeconomic, political and cultural factors. They discuss major complexities and challenges in the sector and conclude that there are ‘good’ enough ‘evidences’ of lack of safe drinking water leading to heavy burden of water-borne diseases in South Asia. However, the ex-isting governance system fails to appreciate and address its link with safe water and sanitation. The authors recommend a more integrated and demand-driven approach to conquer water-related health hazards in South Asia.

Examining the interface of water and health with poverty, Shah and Sajitha (Chapter 3) maintain that ill-health is one of the most important drivers of poverty, particularly in developing economies. The fact that at times even poor are willing to pay for part of the cost of safe drinking water is testimony to the economic loss one would suffer due to inadequate or contaminated water. Despite the clear link between access to safe and adequate drinking water and human well-being, the domestic sector has failed to receive the deserved priority in terms of resource allocation, technical support and institutionalback-up, essential for ensuring ‘water security for all’. In most developing economies, including South Asia, the issue has been merely limited to the supply of water to rural and urban communities, irrespective of quality and sustainability of the water source. Provisioning of safe drinking water to all necessitates more systemic than individual solu-tions. Scarcity of water resources, low level of awareness and limited


paying capacity among a large proportion of the poor reinforces the urgency for systematic solutions. This chapter seeks to attain clearer understanding of the interface between scarcity of safe drinking water, incidence of water-related diseases and poverty in India in order to stimulate an informed policy formulation process on the subject.

Section II focuses on providing evidence on the linkage between water supply and sanitation with human health using case studies and analytical papers. A case study from the central Indian state of Madhya Pradesh, Swain (Chapter 4) reports the spate of malnutrition deaths in the districts of Satna and Khandwa during August–September2008. Marked by high levels of malnutrition, these two districts have limited/low access to potable water and sanitation facilities. A com-bination of factors such as lack of adequate delivery mechanisms and childcare, burden of water management on pregnant women, role of secondary infections in institutional deliveries and continued vul-nerability of children to water-borne diseases impacted the well-being of children and their respective families in these two districts. Although Swain recognises that outbreak investigations can be more complex and the causes of deaths, ill-health multiple, she looks at the lack of important determinants of health, that is access to potable water and sanitation, and how they have impacted some of the worst affected areas of Madhya Pradesh. The chapter traces the divergent planning of various government departments and inadequacies of delivery in these two core sectors. Further, the chapter looks into how it contributed to the burden of under-nutrition and deaths amongst the children. Highlighting some of the positive convergent actions taken by the government in the aftermath of the malnutrition deaths, the chapter urges for a greater focus on pushing the agenda for safe drinking water and sanitation to ensure basic survival of human beings; children in particular.

Joe and Mishra (Chapter 5) present an empirical analysis to com-prehend the distribution of unsafe drinking water, inadequate sanita-tion and childhood under-nutrition in India. For analytical purposes, their study uses data from the Indian National Family Health Survey (2005–06) and employs widely accepted empirical techniques of con-centration index and curve. The analysis indicates that across several regions in India, access to safe drinking water and sanitation are at


unacceptably low levels. Additionally, using the concentration index, it becomes clear that there are stark inequalities in access to safe drinking water and sanitation. Furthermore it is noticed that distribution of safe water and adequate sanitation are signifi cantly associated with the distribution of childhood under-nutrition across different states. Maternal education and household income status have also emerged as prominent correlates determining a child’s nutritional status. The chapter concludes that provisioning of safe water and sanitation can be more effective in reducing under-nutrition only when household endowments, in terms of income and maternal education, are also improved.

Fitzpatrick et al. (Chapter 6) examine the linkage between water and health in two primarily low caste villages in Dhanusha district of Nepal by evaluating their mortality, morbidity and nutritional status. Ninety-fi ve deaths occurred over fi ve years, refl ecting 5.1 per cent of the population (10 deaths per 1,000 person-years). Primary causes of death were respiratory/pneumonia (17 per cent), cardiovascular diseases (14 per cent), stomach problems/diarrhoea (10 per cent), and ‘witchcraft’ (5 per cent). Prevalence of morbid conditions was highest in children for diarrhoea, fever, intestinal worms and skin infections. Results of the survey in two villages indicate that the high prevalence of mortality, morbidity and malnutrition is largely due to inadequate access to safe drinking water and sanitation facilities in the villages. The chapter calls for the government and non-governmental organizations (NGOs) to ensure clean drinking water and sanitation for achieving MDGs by 2015.

Calculating the burden of disease linked to incomplete water and sanitation coverage in the state of Orissa in India, Cronin and Dutta (Chapter 7) found an unacceptably large burden of disease associated with poor water and sanitation provision and show that the state diarrhoeal estimates are in excess of national fi gures. Using the World Health Organization (WHO) methodology for estimating the burden of disease related to incomplete water and sanitation coverage, the chapter analyses morbidity and mortality data relating to the most critical water-borne disease burdens (that is diarrhoea and malaria) in the state. Findings of this analysis demonstrate that disease burden underline signifi cant suffering, and associated social burden among


the population can be attributed to incomplete water and sanitation provisions and can aid resource managers to compare among various districts. Further, it can identify those requiring additional expertise or resources specifi c to water and sanitation. The chapter calls for increased dialogue and collaboration across water, sanitation and health sectors.

Section III examines the concerns on intensifi cation of agriculture and consequent impact on water and health. Providing information on arsenic contamination and toxicity in India and Bangladesh, Sankararamakrishnan and Iyengar (Chapter 8) report how this con-tamination spreads from groundwater usage. Groundwater is used as the primary source to provide safe drinking water in West Bengal and Bangladesh. Millions of hand pumps and deep tube wells have been installed across India and Bangladesh to provide safe water free from bacteriological contaminations. However, the emerging toxicity of groundwater due to arsenic contamination has raised health alarms in both these countries. Besides skin lesions, arsenic contamination can lead to aggravation of diseases like heart disease, cancer, respiratoryproblems, renal failure, low birth weight and under-development among children. This chapter focuses on the arsenic contamination status in Bangladesh and India, its toxicity, various exposure routes and health effects.

Taking the issue of arsenic contamination further, Guha and Gupta (Chapter 9) provide a case study that links arsenic toxicity with pregnancy outcomes in West Bengal, India. Arsenic is the most serious inorganic contaminant with toxic properties in drinking water derived from groundwater worldwide. The study examines the adverse pregnancy outcomes among two groups of women—those exposed to various concentrations of arsenic and those who remained unexposed. This cross-sectional case-control study was conductedin Murshidabad, one of the arsenic-affected districts of West Bengal, in 2006. The study reported adverse pregnancy outcomes among women exposed to arsenic in terms of spontaneous abortion, stillbirth and preterm birth rates. The chapter establishes that arsenic in drinking water is an important hazard in pregnancy, and every effort is needed to protect women from high risk.


Reporting from the saline groundwater pockets in Mewat region of Haryana in India, Sharma, Satyavada and Chowdhury (Chapter 10)show how fresh groundwater is available only in a few pockets while most of the water sources are saline. Lack of fresh water has far-reaching consequences that have a bearing on the district’s economy, socio-political setup and the health status of its inhabitants. Against this backdrop, this chapter focuses on solutions to create a pocket of fresh groundwater within a saline aquifer. The chapter describes experiences from Karheda, a village in Mewat that adopted a unique approach to address the issue of groundwater salinity. The approach involves using innovative roof water harvesting (RWH) technique for collection, storage and conservation of rain water and use of bio-sand fi lters to make the water safe for human consumption. This model was developed after a thorough evaluation of a range of technologies for their suitability, sustainability and affordability, backed by situational analysis of the village. The model has been successfully demonstrated in a government school complex in Karheda village and has been adopted by 30 households in and around the area. Experiences from this pilot project suggest that the model is sustainable, affordable and can be replicated in areas where groundwater is saline.

Section IV tries to bring out the inter-relations between rapid indus-trialisation and its implications on water and health. Documenting a case from Faisalabad region in Pakistan on wastewater use in vegetable production, Abedullah, Kousar and Abbas (Chapter 11) reveal that the use of wastewater, fl owing from industries, in urban/peri-urban farming is a common phenomenon in Pakistan. Vegetable production using wastewater has adverse impacts on human health. In this chapter, an attempt has been made to estimate the economic value of negative externality of wastewater use in vegetable production in peri-urban areas of Faisalabad. The present study helps to estimate the economic values of negative health externalities and to evaluate the wastewater use in vegetable production. The main focus is on labour productivity loss due to ill- health and medical expenditures incurred by farmers as a result of wastewater use. Data from the vegetable growers was collected by dividing them into two groups, that is vegetables using and not using untreated wastewater. The economic value of untreated wastewater use is estimated by adopting cos—benefi t approach with


and without internalizing the external cost. The results clearly illustratethat net social benefi ts of vegetable production using untreated wastewater are negative, and the value of negative profi t (net loss) is US$ 2426 per acre per crop while this loss increases when calculated for the whole year and is US$ 9705 per acre. Hence, among differ-ent solutions, the installation of treatment plants through taxation on industrialists is one option. Nevertheless, the moral and ethical consideration by the growers themselves will positively add to reduce the disease burden and therefore, to get rid of this immense economic and social loss.

Examining the factors that infl uence farmers’ willingness to protect groundwater from sources of pollution, Mukherjee (Chapter 12) reveals that controlling the sources of water pollution is particularly crucial in rural areas where groundwater is an important source of drinking water. The chapter captures the factors infl uencing farmers’ perceptions about groundwater quality and their willingness to pro-tect groundwater from non-point sources of pollution in the lowerBhavani River Basin, Tamil Nadu. To understand the factors infl uencing farmers’ willingness to support the local government to supply safe drinking water through alternative arrangements, binary choice Probit models were estimated. Six villages were identifi ed in the basin on the basis of long-term groundwater nitrate concentrations and sources of irrigation. The results show that farmers’ perceptions of risks related to groundwater nitrate pollution vary across villages, and mimic the actual groundwater nitrate situation. Estimated results of binary choice Probit models show that farmers from villages where groundwater is comparatively highly contaminated from nitrate are willing to pro-tect groundwater as compared to farmers from less affected villages. Demand for safe drinking water varies across the villages, based on the variations of socio-economic characteristics of the sample households and groundwater quality of the villages.

Reporting on the inter-linkages of industrial pollution with health from a textile cluster in Tamil Nadu, India, Nelliyat (Chapter 13), studies the improper waste management in industrial pollution inTiruppur where around 700 bleaching and dyeing units discharge more than 80 mld of effl uents without proper treatment. The con-tinuous discharge of effl uents and leachate from the sludge has resulted


in polluting the region’s water sources. The impact of pollution is observed in the groundwater and surface water sources. Even if effl u-ent treatment plants are installed, they are not functioning effectively. Through a case study of Tiruppur, the author attempts to evaluate water contamination and potential health risks in the context of industrial pollution in the globalisation era. There are three ways in which textile pollutants may lead to health problems: (i) direct con-sumption and use of contaminated water for other domestic purposes, (ii) use of polluted water for food crops and accumulation of toxic pollutants in food and (iii) toxicity among fi sh grown in the polluted surface water sources. Tiruppur earned global recognition in knitwear manufacturing and exports. However, pollution issues and possible health risks continue primarily due to market, policy, institutional and technological failures.

Establishing the link between mining and human health from a case in Orissa, India, Pattanaik (Chapter 14) shows mining is an un-sustainable industry and does not lead to economic and social well-being of the local people. The state of Orissa in India has been facing this challenge since liberalization when it embarked upon a major reform programme in the mining sector. Ever since, the impact of mining upon natural ecosystems, biodiversity and tribal livelihoods has become a key concern and source of confl ict in Orissa. In this context, the chapter assesses the socio-economic and environmental impacts of mining in Keonjhar district, located in the Baitarani River ecosystem, in the northern part of the state. The chapter documents the fi ndings of a study conducted in 2007 to understand the impact of iron ore mines and sponge and steel industries on the region’s water regime and on the health status of the local community. The study reveals that degradation of water quality and water shortage impact the livelihoods of the tribal poor in the mining belt. This crisis is largely due to the depletion of groundwater, pollution of surface water bodies along with disappearance of perennial streams fromthe hills where mines are based, and acute drinking water scarcity. The tribals experience degradation of water quality, air quality and forest resources, all central to their livelihoods in the mining belt.The chapter also shares interventions that can help mitigate the negative impacts on human health and ecosystem and introducing effective environmental management in the matter of ‘water sources’.


Section V focuses on the consequences of increasing urbanisation on water and health. Studying the health implications of misman-agement of domestic and municipal wastewater in Sri Lanka, Najim and Rajapakshe (Chapter 15) report that Sri Lanka experienced rapid urbanisation and industrialisation in the 1970s, but without adequate infrastructural development, resulting in severe problems in wastewater disposal and management. Populated cities and estate communities dispose of wastewater, including grey-water, black-water and solid wastes, directly into water bodies. This chapter reports on the health implications of water pollution and mismanagement inSri Lanka through two case studies. Water pollution due to domestic and municipal discharges have affected potable sources of water, posing serious health hazards that represent the limitations and gaps in the implementation of such interventions in the country.

Examining the health implications of water use in peri-urban South Asia, Narain (Chapter 16) reports how urbanisation processes affect peri-urban residents’ access to water and its various uses, and how such processes impact human health and well-being. Access to water depends on the prevailing land tenure system. Settlements on the peripheries of cities are often outside the ambit of public or organised sources of water supply, resulting in inhabitants’ relying on contaminated groundwater and growing more vulnerable to water-borne diseases. The issue of wastewater irrigation in peri-urban areas demand immediate attention. While wastewater irrigation enables farmers to tap alternative sources of water, thereby increasing their livelihood opportunities, it has serious health implications, especially in countries like Pakistan and India where wastewater farming is practised. The paper examines the underlying policy and institutional factors behind such trends, offering a menu of options for addressing these challenges, highlighting in particular, the role of community initiatives. Some successful initiatives in the region have also been highlighted.

Providing a case study of Bhaktapur drinking water, sanitation and irrigation systems in Nepal, Pradhan (Chapter 17) illustrates the adverse impact on public health of a large scale water supply and sanitation system introduced by an external agency. Bhaktapur sub-metropolis, with a population of 70,000, forms a fl at plateau.


Old Bhaktapur received its water supply from an irrigation channel constructed in the 17th century. The channel fed water to stone water spouts and multi-purpose ponds, including groundwater recharge.In the 1970s, the Government of Federal Republic of Germany assisted the Bhaktapur Development Project (BDP) in the restorationand conservation of the ancient temples and the old traditional houses. Later, a piped drinking water supply system was installed through public stand posts. However, the people kept using wells, spouts, ponds and public stand posts for water for drinking and other domestic uses. The chapter analyses how improper functioning of infrastructure for maintenance of water quality, weak regulations and non-compliance of sewerage disposal standards by the end users resulted in public health hazards and environmental damage of the town. This case study shows a classic example of superimposition of traditional and modern system without congruency that led to the programme failing to meet the needs of local people.

Section VI deals with the issue of water and health in the wake of natural disasters. Exploring the inter-relations between water,health and natural disasters in the context of Bangladesh, Nahar et al.(Chapter 17) focuses on peoples’ experience and perspective, with specifi c reference to fl oods, droughts and cyclones. The account pre-sented in this chapter is based on a broader study which aimed to defi ne ‘health security’ in the context of natural disasters. The study revealed that in rural Bangladesh, water problems due to natural disaster not only create health hazards but also affect people’s earnings, cultiva-tion and daily activities, irrespective of gender and socio-economic status, creating vulnerability to further health hazards. The vulnerable always suffer most from health hazards, which in this case, are very disproportionately represented by women and the poor.

Providing an account of the humanitarian response to tsunami in India, Krishna and Chodhury (Chapter 18) reveal how the tsunami damaged the water, sanitation and public health infrastructure in coastal states of Tamil Nadu, Andhra Pradesh, Kerala and in the Andaman and Nicobar Islands in India. Post-tsunami, humanitarian agencies were confronted with the massive challenge of providing water and sanitation facilities and public health services. The chapter dwells on the question, how well-equipped are governments, humanitarian


agencies and communities in emergency public health promotion?It provides an account of public health challenges faced in the aftermath of a major disaster and argues for a public health promotion plan to enable people to take action to prevent or mitigate disease.

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∗ This is a modified version of Chourey, Jayati and Anjal Prakash. 2010. ‘Good Evidences, Bad Linkages: A Review of Water and Health in South Asia’. Asian Journal of Water, Environment and Pollution, 7(1): 5–17.

2

Good Evidences, Bad Linkages

A Review of Water and Health in South Asia∗

JAYATI CHOUREY AND ANJAL PRAKASH

INTRODUCTION

SOUTH ASIA IS marked by an increasing population, rapid urbanisation, unsustainable agricultural and industrial development and poor waste management regulations that affect the environment which in turn affects food production and human health. This chapter provides an overview of the status of water and health in South Asia. Good Evidences, Bad Linkages narrates the story of water and health in South Asia where there are ‘good’ enough ‘evidences’ of lack of safe water leading to the heavy burden of water associated diseases. This scenario worsens due tobad ‘interlinkages’ of water and health at the policy and programme levels. The existing governance system aims to provide good health but fails to appreciate and address its links with safe water supply and sanitation. This chapter is divided into three. Part 1 provides an overview of water and health using country level secondary data on water supply and sanitation and prevalence of water-associated diseases to understand the extent of water and health problems in South Asia. Part 2 discusses the major challenges in providing access to water and health in South Asia with country specific examples. Part 3 provides conclusions with an agenda for action.

22 Jayati Chourey and Anjal Prakash

STATUS OF WATER AND HEALTH IN SOUTH ASIA

South Asia comprises of Afghanistan, India, Pakistan, Bangladesh, Nepal, Bhutan and the island nations of Sri Lanka and Maldives. Con-sidered one of the fastest growing regions in the world, and the most diverse, South Asia is home to half of the world’s poor with approxi-mately half a billion people living on less than a dollar a day. In 2005, the average Human Development Index (HDI) for the region, basedon three measurable dimensions of human development—living a long and healthy life, education, and having a decent standard of living—was 0.546 compared to the world average of 0.741.

According to the ‘Basic Statistics 2006’ of Asian Development Bank (ADB 2006), poverty levels in the region, as defined by national poverty lines, ranged from 49.8 per cent in Bangladesh to 30.9 per cent in Nepal and 26.1 per cent in India to 25.3 per cent in Bhutan (Babel and Wahid 2008). Poverty alleviation is the biggest challenge for South Asian countries. It is also obvious that the world’s poorest region is marked by disparities in access to water supply and sani-tation, one of the basic services for healthy living. ‘Water contributes to poverty alleviation in many ways—through sanitation services, water supply, affordable food and enhanced resilience of poor communities faced with disease, climate shocks and environmental degradation. Water of the right quality can improve health through better sani-tation and hygiene and when applied at the right time can enhance land productivity, labour and other productive inputs.” (Björklund et al. 2009: 80). The next sub-section throws light on the status of water and sanitation coverage across South Asia.

Water and Sanitation Coverage in South Asia

South Asia is the most densely populated region in the world, home to nearly a quarter of the world population. The region is endowed with vast water resources but the available water is unevenly distributed over space and time (GWP–South Asia undated). Table 2.1 provides the water supply and sanitation coverage for all the eight South Asian countries. Based on 2006 Joint Monitoring Programme of UNICEF and World Health Organization, the data reveals that water supply sector is doing better than sanitation with exception in Afghanistan.

Good Evidences, Bad Linkages 23

Water supply ranges from a low of 22 per cent in Afghanistan to a highof 98 per cent in Sri Lanka. Similarly, data on access to improved sani-tation shows a range of 27 per cent in Nepal to 86 per cent in Sri Lanka. The high percentage of water supply and sanitation in Sri Lanka is attributed to government initiatives during early 1970s and 1980s in improving water supply and sanitation1.

In terms of water supply, except in the case Afghanistan, popu-lation covered ranges from 80 to 90 per cent, indicating considerable achievements. Nepal, India and Pakistan have been able to provide water coverage to a considerably large population in 16 years, covering about 46, 41 and 35 per cent more of its population, respectively. On the sanitation front, Pakistan has been able to provide access to safe places for defecation to about 40 per cent more of its people (Table 2.2).

However, sanitation coverage in the region is still poor, despite government’s claims, as the government figures mostly show the available infrastructure rather than the status of the resource itself. Water resources in South Asia are increasingly becoming scarce and mismanaged. This has a direct bearing especially on the status of domestic water supply. The scarcity of water is manifested in depletinggroundwater resources, issues of water quality and competing demands. Apart from the quantity problems, the microbial andchemical contamination of freshwater bodies and quality of ground-water has been a major threat to drinking water supply.

1 The primary responsibility of providing and managing water supply and sani-tation services in Sri Lanka was divided between two key agencies among others, namely the Water Supply Division of the then Ministry of Irrigation, Power and Energy for the water supply sector and the Ministry of Health for the sanitation sec-tor before 1975. The local authorities were assigned the responsibility for providingpiped water and public wells. This institutional arrangement for the provision and management of water supply and sanitation services changed in 1974 when the National Water Supply and Drainage Board (NWSDB) was established through an act of Parliament under the then Ministry of Irrigation, Power and Highways. NWSDB became the primary agency responsible for water supply and sanitation in the country. The current coverage level of water supply and sanitation is largely attributed to this initiative of the Sri Lankan government (ADB 2007).

Tab

le 2

.1:

Wat

er a

nd S

anit

atio

n C

over

age

in S

outh

Asi

an C

ount

ries

, 200

6

Cou

ntry

Popu

latio

nIm

prov

ed W

ater

supp

lyC

over

age2 (

%)

Impr

oved

San

itatio

nC

over

age3 (

%)

Tot

al(t

hous

ands

)%

Rura

l%

Urb

anT

otal

Urb

anRu

ral

Tot

alU

rban

Rura

l

Afg

hani

stan

26,0

8874

2622

3717

3045

25B

angl

ades

h15

5,99

175

2580

8578

3648

32B

huta

n64

981

1181

9879

5271

50In

dia

151,

751

7329

8996

8628

5218

Mal

dive

s30

070

3083

9876

5910

042

Nep

al27

,641

8416

8994

8827

4524

Paki

stan

160,

943

6535

9095

8758

9040

Sri L

anka

19,2

0785

1582

9879

8689

86

Sour

ce:

WH

O–U

NIC

EF J

MP

(200

8).

2 An

impr

oved

drin

king

wat

er so

urce

is d

efin

ed a

s a d

rinki

ng w

ater

sour

ce o

r del

iver

y po

int t

hat,

by n

atur

e of

its c

onst

ruct

ion

and

desig

n,

is lik

ely

to p

rote

ct th

e w

ater

sour

ce fr

om o

utsid

e co

ntam

inat

ion,

in p

artic

ular

from

faec

al m

atte

r. T

he Jo

int M

onito

ring

Prog

ram

me

(JM

P)

incl

udes

pip

ed w

ater

into

dw

ellin

g, p

lot o

r yar

d; p

ublic

tap/

stan

d pi

pe; t

ube w

ell/b

oreh

ole;

pro

tect

ed d

ug w

ell;

prot

ecte

d sp

ring

and

rain

wat

er

colle

ctio

n as

impr

oved

drin

king

wat

er so

urce

s.3

An

impr

oved

san

itatio

n fa

cilit

y is

defi

ned

as o

ne t

hat

hygi

enic

ally

sep

arat

es h

uman

exc

reta

from

hum

an c

onta

ct. I

n JM

P da

ta, s

ani-

tatio

n fa

cilit

ies a

re n

ot c

onsid

ered

impr

oved

whe

n sh

ared

with

oth

er h

ouse

hold

s, or

ope

n fo

r pub

lic u

se. I

mpr

oved

sani

tatio

n m

eans

hav

ing

acce

ss to

flu

sh o

r pou

r-fl

ush

toile

t to

[1] p

iped

sew

er sy

stem

, [2]

sept

ic ta

nk a

nd [3

] pit

latr

ine;

ven

tilat

ed, i

mpr

oved

pit

latr

ine;

pit

latr

ine

with

slab

; and

com

post

ing

toile

t.


Table 2.2: Percentage of Additional Population Gained Coverage between 1990 and 2006 with Respect to Median Population, 1998

Country Water Supply Safe Sanitation

Afghanistan No Data No DataBangladesh 27 21Bhutan No Data No DataIndia 41 20Maldives 15 No DataNepal 46 25Pakistan 35 40Sri Lanka 23 24

Source: WHO–UNICEF JMP (2008).

Environmental Pollution and Water Quality in South Asia

The problem of insufficient and ill-managed water supply is further compounded by poor quality of freshwater supply in the region, which is threatened by pollution, ecosystem degradation, changing land-use and indiscriminate development. For instance, the river Ganges in India receives raw sewage from 114 towns and cities. The problem of water quality does not end with microbial contamination of surface water. Groundwater, especially shallow groundwater, in many sites of South Asia is contaminated with dangerously high levels of arsenic, fluoride and nitrates. The Jaffna Peninsula in Sri Lanka faces nitrate problem in its shallow groundwater aquifers due to dumping from latrines. Bangladesh is struggling with arsenic poisoning as millions of people are exposed to potentially fatal quantities of arsenic. According to UNICEF (2010) approximately 20 million people at risk of arsenic exposure. Intensive agricultural production practices to increase crop yields for feeding the ever-growing population has resulted in unprec-edented risks for the water resources. Fertilisers and pesticides used in agriculture readily penetrate the groundwater resources, while run-off caused due to rains increases contaminant levels in surface waters (Smith 2001).

South Asian economies are developing. This translates into the economy getting more reliant towards industrial production, primarily manufacturing. A common by-product of this industrial explosion is industrial waste, a mélange of chemicals that pose substantial risk to


human health. This is a risk, particularly in the South Asian region, as industrial growth is occurring in the background of weak or rather evolving/half-baked policies. Companies that generate waste have strong financial incentives to pollute, based on the subsidies provided by governments to promote industrial growth. Paying to pollute would reduce this contamination, but would reduce profits (Luby 2008).Illegal discharges from small-scale industries are difficult to regulate and control.

Since independence, India has had strong policies to promote the small-scale industrial sector. This sector, being labour intensive, creates more jobs and contributes to decentralised industrial development.Its units are flexible and are able quickly to reorganise for the emerging market demands. In these units, Western technological systems are primarily adopted leading to production of enormous gaseous, liquid and solid wastes. But the pollution control technologies developed in the West are not economically suitable for these home-grown enter-prises. Their numbers are huge and so is the pollution from them. They contribute about 40 per cent of the total industrial wastewater in India (Agarwal undated).

Indeed, the frequency of water contamination is so common throughout South Asia that it is a necessary evil. A small percentage of the populace can afford to buy bottled water (again, of spurious quality), but the majority consume the available contaminated water (Luby 2008). However, countries in South Asia are beginning to put in place water quality laws, to make low-cost test kits for water qualitymonitoring available at the community level. Awareness of water quality issues is increasing and Water Safety Plans are more widely used. People’s expectations for increased quantity of improved water supply should, however, be matched with considerations for improved waste water disposal in order to prevent contamination of surfaceand groundwater.

Status of Water-associated Diseases in South Asia

An important share of the total burden of disease worldwide—around 10 per cent—could be prevented by improvements in drinkingwater availability, sanitation, hygiene and water resource management (Prüss-Üstün et al. 2008). Bradley estimated that excellent water


supply can reduce most diarrhoea and dysentery (by 50 per cent), typhoid fever (by 80 per cent), paratyphoid, other salmonella (by 40 percent), trachoma (by 60 per cent), scabies (by 80 per cent), skin and subcutaneous infections (by 50 per cent), urinary schistosomiasis(by 80 per cent) and intestinal schistosomiasis (by 40 per cent)(White et al. 1972, quoted in Cairncross and Valdmanis 2006) Although 85 per cent of drinking water in South Asia meets the target of the Millennium Development Goals (MDGs) of coming from an improved source (UNICEF 2006), this water is, in fact, frequently contaminated with human faecal organisms and toxic chemicals (Tambe et al. 2008, Anwar et al. 2004 and Islam et al. 2007, quoted inLuby 2008). The failure to deliver clean water to the South Asian popu-lation means more childhood deaths, less cognitive development, less educational achievement and less economic growth (Luby 2008).

Diseases related to water is among the top 10 causes of death in the region (Mathers et al. 2006). Based on the literature survey 25 types4 of diseases associated with water have been identified in South Asia. The mortality due to water-related diseases has decreased in the past 10 years, but morbidity is on the rise in the region. Tables 2.3a and 2.3b present country level data on water-, sanitation- and hygiene-related diseases in South Asia for 2002. In 2002, percentages of total deaths caused due to water- sanitation- and hygiene-related diseases in the region ranged from 1.9 per cent in the case of Sri Lanka to 16.2 per cent in the case of Afghanistan, while disability-adjusted life years (DALYs) attributable to lack of water, sanitation and hygiene, ranged from 3.2 per cent in Sri Lanka to 15.8 per cent in Afghanistan (Prüss-Üstün 2008). Both the parameters related to burden of water-related diseases indicate that Afghanistan and Pakistan are the most affected countries, while Sri Lanka has made considerable progress in health outcomes.

4 As per WHO, the following water-associated diseases are prevalent in South Asia: anaemia, arsenicosis, ascariasis, bacillary ‘ dysentery (shigellosis), chikungunya, campy-lobacteriosis, cholera, cyanobacterial toxins, dengue and dengue’ haemorrhagic fever, diarrhoea, drowning and other water related injuries, filariasis fluorosis, hepatitis, Japanese encephalitis ( JE), lead, poisoning, leptospirosis, malaria, malnutrition, methaemoglobinemia, polio, ringworm (tinea), scabies, trachoma, typhoid and paratyphoid enteric fevers.

Tab

le 2

.3a:

D

eath

s (’0

00)

Att

ribu

tabl

e to

Wat

er, S

anit

atio

n an

d H

ygie

ne in

200

2

Dea

th a

nd/In

jury

Afgh

anist

anBa

ngla

desh

Bhut

anIn

dia

Mal

dive

sPa

kista

nN

epal

Sri L

anka

Popu

latio

n 22

,930

143,

809

2,19

010

4,95

5030

914

9,91

124

,609

18,9

10T

otal

dea

ths

484.

511

06.8

21.0

1037

8.5

2.1

1386

.423

3.3

145.

5T

otal

WSH

-rel

ated

78.5

109.

91.

978

2.0

0.1

187.

924

.72.

7T

otal

dea

ths

(per

cent

age)

16.2

9.9

9.2

7.5

6.0

13.6

10.6

1.9

Dia

rrho

eal d

iseas

es36

.860

.31.

240

2.2

0.0

103.

314

.70.

6In

test

inal

nem

atod

e in

fect

ions

0.0

0.2

0.0

3.2

0.0

0.8

0.1

0.0

Mal

nutr

ition

(onl

y PE

M)

3.2

1.0

0.0

8.7

0.0

2.5

0.5

0.0

Con

sequ

ence

s of m

alnu

triti

on19

.526

.00.

321

7.0

0.0

51.7

4.3

0.1

Tra

chom

a0.

00.

00.

00.

00.

00.

00.

00.

0Sc

hist

osom

iasis

0.0

0.1

0.0

0.0

0.0

0.0

0.1

0.0

Lym

phat

ic fi

laria

sis0.

00.

00.

00.

00.

00.

00.

00.

0Su

btot

al w

ater

sup

ply,

san

itat

ion

and

hygi

ene

59.6

87.5

1.5

631.

20.

115

8.3

19.7

0.8

Mal

aria

0.3

0.6

0.0

3.4

0.0

0.6

0.0

0.4

Den

gue

0.0

2.0

0.1

5.2

0.0

0.5

0.2

0.0

Cou

ntry

Lev

el D

ata

on W

ater

, San

itatio

n an

d H

ygie

ne-r

elat

ed D

iseas

e B

urde

n

Onc

hoce

rcia

sis0.

00.

00.

00.

00.

00.

00.

00.

0Ja

pane

se e

ncep

halit

is0.

00.

70.

06.

60.

02.

30.

20.

0Su

btot

al w

ater

res

ourc

e m

anag

emen

t0.

33.

30.

115

.10.

03.

40.

40.

5

Dro

wni

ngs

1.7

6.1

0.1

50.4

0.0

5.9

1.3

0.7

Subt

otal

saf

ety

of w

ater

en

viro

nmen

ts1.

76.

10.

150

.40.

05.

91.

30.

7

Oth

er in

fect

ious

dise

ases

16.8

13.0

0.3

85.3

0.0

20.3

3.4

0.9

Sour

ce:

Prüs

s-Ü

stün

(200

8).

Tab

le 2

.3b:

D

ALY

s∗ (

’000

) A

ttri

buta

ble

to W

ater

, San

itat

ion

and

Hyg

iene

in 2

002

Dise

ase o

r Inj

ury

Afgh

anist

anBa

ngla

desh

Bhut

anIn

dia

Mal

dive

sPa

kista

nN

epal

Sri L

anka

Tot

al D

ALY

s17

,011

.036

,972

.164

4.1

299,

909.

859

.744

,821

.27,

469.

13,

499.

8T

otal

WSH

-rel

ated

2,69

1.8

4,05

8.1

65.1

29,2

13.3

4.5

6,43

7.5

873.

511

1.7

Tot

al D

ALY

s (p

erce

ntag

e)15

.811

.010

.19.

47.

514

.411

.73.

2D

iarr

hoea

l dise

ases

1,19

2.4

2,01

3.3

39.4

13,6

44.2

1.5

3,29

849

2.2

28.4

Inte

stin

al n

emat

ode

infe

ctio

ns13

.079

.01.

559

4.8

0.2

109.

615

.315

.8

Mal

nutr

ition

(onl

y PE

M)

153.

726

7.1

3.7

1493

.20.

528

0.1

55.5

7.8

Con

sequ

ence

s of

mal

nutr

ition

676.

689

0.0

8.7

7421

.20.

717

64.0

149.

64.

3

Tra

chom

a5.

316

.50.

013

8.1

0.0

15.7

2.9

0.0

Schi

stos

omia

sis0.

00.

90.

00.

00.

00.

00.

80.

1Ly

mph

atic

fila

riasis

0.0

142.

80.

010

11.4

0.3

0.1

24.1

12.5

Subt

otal

wat

er s

uppl

y,

sani

tati

on a

nd h

ygie

ne20

41.1

3409

.753

.324

302.

93.

254

67.4

740.

468

.7

Mal

aria

23.1

44.1

0.4

303.

70.

161

.15.

317

.1D

engu

e0.

167

.82.

017

5.4

0.0

18.5

6.4

1.0

Onc

hoce

rcia

sis0.

00.

00.

00.

00.

00.

00.

00.

0Ja

pane

se e

ncep

halit

is0.

923

.20.

721

4.1

0.1

77.4

5.2

0.0

Subt

otal

wat

er r

esou

rce

man

agem

ent

24.1

135.

03.

169

3.2

0.2

157.

116

.818

.1

Dro

wni

ngs

57.5

181.

72.

813

92.2

0.2

171.

239

.915

.6Su

btot

al s

afet

y of

wat

er

envi

ronm

ents

57.5

181.

72.

813

92.2

0.2

171.

239

.915

.6

Oth

er in

fect

ious

dise

ases

569.

133

1.6

5.8

1825

.00.

964

1.8

76.2

9.3

Sour

ce:

Prüs

s-Ü

stün

(200

8).

∗ D

ALY

: The

WH

O g

loba

l bur

den

of d

iseas

e (G

BD

) mea

sure

s the

bur

den

of d

iseas

e us

ing

the

disa

bilit

y-ad

just

ed li

fe y

ear (

DA

LY).

Thi

s tim

e-ba

sed

mea

sure

com

bine

s ye

ars

of li

fe lo

st d

ue to

pre

mat

ure

mor

talit

y an

d ye

ars

of li

fe lo

st d

ue to

tim

e liv

ed in

sta

tes

of

less

than

full

heal

th.


Cases of water-transmitted diseases have been most frequent in South Asian countries. Diarrhoea still remains the primary cause formajority of deaths in the region. Nearly one million children died from preventable diarrhoeal diseases during 2006–08 (Kothari 2008). As per the Annual Health Bulletin 2007, Royal Government of Bhutan, Ministry of Health, diseases linked to water, including diarrhoea, malaria and skin diseases, are among the 10 most common causesof morbidity. Diarrhoeal diseases in summer still top the list of infant morbidity due to poor quality of drinking water and sanitation.Diarrhoea, malaria, jaundice are three of the major diseases prevalent in India and Bangladesh. As per WHO statistics, in Maldives worm infestation is high in the country and 50–75 per cent of children below five years of age are estimated to be affected by intestinal parasites. Skin infections, diarrhoeal diseases and intestinal worms are three domi-nant diseases in Nepal. India, Pakistan and Afghanistan are now among the only few countries in the world with wild-type polio.

Meanwhile, Sri Lanka has shown significant improvement in its health sector and presents a transitional mortality pattern. It appears to be moving away from a pattern seen in developing countries to a pattern observed in developed countries. In Sri Lanka, the trends in mortality indicate a decrease in deaths resulting from infectious and parasitic diseases.

Though the general trends in most of the South Asian countries are negative, morbidity is still very high and significant. Take India, where reported deaths due to cholera reduced from 20 in 2000 to three in 2007, while the number of reported cholera cases declined from 4,053 in 2000 to 2,635 in 2007. Similarly, malaria, another major public health problem, claimed 2,803 lives during 1996 in India, which reduced to 990 in 2003, whereas the number of reported malaria cases showed a decline from 2,207,431 in 1993 to 1,781,336 in 2003, which is still very high. Higher morbidity and lesser mortality clearly indicate that the strategies adopted by the countries to conquer water-related disease are curative-oriented rather than prevention-oriented. On the other hand, there are two distinct trends in Japanese encephalitis (JE) incidences. In countries such as Bangladesh and India, where no specific diagnostic centres, vaccination programmes and surveillance systems are in place, the incidence of JE appears to have increased in


recent years. On the contrary, in Sri Lanka, where vaccination pro-grammes are being implemented and regular surveillance is pursued, the incidence of JE is declining (Erlanger et al. 2009).

However, problems concerning water and health do not end with microbiological contamination. Besides infectious diseases, chemical contamination of surface and groundwater also create a great threat to public health (Luby 2008). Scarcity and pollution of surface water has led communities to use groundwater as an alternative source for various purposes, mainly for drinking and food production. Countries like India, Bangladesh, Pakistan and Nepal are struggling with arsenic poisoning as at many sites arsenic in drinking water has been detected at concentrations greater than the Guideline Value, 0.01 mg/l or the prevailing national standard (WHO 2001). Arsenic contamination ingroundwater in these countries is known to be of geological origin (Sarkar 2008) and also appears to be exaggerated by present anthro-pogenic activities (Acharyya et al. 2000). In Banglasdesh, when UNICEF introduced wells during the 1970s and 1980s to supply drinking water safe from microbial contamination, it ended up in a bigger tragedy of arsenic contamination (Datta and Subramanian 2002, Kjellstrom et al.2006, Caldwell 2008). UNICEF (2010) estimate that 20 million people of Bangladesh’s population is exposed to arsenic contamination. Maddison et al. 2004 (as quoted by World Bank 2005: 5), estimates that in Bangladesh 6,500 people will die from cancer every year, a total of 326,000 people in a period of 50 years, while 2.5 million people will develop some kind of arseniocosis in one year.

In India, seven of the 16 districts of the state of West Bengal have been reported to have groundwater arsenic concentrations above0.05 mg/l; the total population in these seven districts is over 34 mil-lion (WHO 2001). In Nepal, as per UNICEF estimations, arsenic contamination could affect more than 1.4 million people (about 47 percent of its population) across 20 districts in Terai (Lawoti 2006). Even in Pakistan, arsenic contamination is an emerging threat to public health. In Punjab province over 20 per cent of the population is ex-posed to arsenic contamination of over 0.01 mg/l in drinking water, while nearly 3 per cent of the population is exposed to over 0.05 mg/l. In Sindh province, the situation is even worse with 36 per cent and 16 per cent of population exposed to arsenic contaminated water over


0.01 mg/l and 0.05 mg/l respectively. Both shallow and deep sources were found contaminated by arsenic (Ahmad et al. 2004).

High concentration of fluoride in drinking water in Afghanistan, Pakistan, India, Bangladesh and Sri Lanka pose further difficulties. Fluoride in water is mostly of geological origin in the region. High concentrations of fluoride have been reported in groundwater from India, Pakistan and Sri Lanka. The WHO noted that mottling of teeth (that is dental fluorosis) is sometimes associated with fluoride levels in drinking water above 1.5 mg/l and crippling skeletal fluorosis can ensue when fluoride levels exceed 10 mg/l. Fawell et al (2006) quote Dissanayake (1991) who reported dental and possibly skeletal fluorosis in the dry zone, associated with usage of groundwater con-taining fluoride concentrations of up to 10 mg/l in groundwater in Sri Lanka,

Endemic fluorosis is one of the major national health problems in India. In 1991, 13 of India’s 32 states and union territories were reported to have had naturally high concentrations of fluoride in water (Mangla 1991), but this number rose to 17 by 1999 (UNICEF 1999). Andhra Pradesh, Punjab, Haryana, Rajasthan, Gujarat, Tamil Nadu and Uttar Pradesh (Kumaran et al. 1971, Teotia et al. 1984) are the mostseriously affected areas. The highest concentration recorded in India to date is 48 mg/l in Rewari district of Haryana (Garg et al. 2009).

No published estimates are available on the burden of disease from the overall effects of other chemical pollutants in water for South Asia. There are 1,176 industrial units in Bangladesh that heavily pollute the environment. The statistics from the Department of Environment, Bangladesh put the number of polluting textile mills at 365, tanneries at 198, pharmaceutical units at 149, engineering workshops at 129, chemical and pesticide factories at 118, jute mills at 92, rubber and plastic units at 63, food and sugar at 38, plastic recycling factories at 125, paper and pulp at 10, cement and fertiliser at 5 each and dis-tilleries at 4. A study conducted by the Society for Environment and Human Development (SEHD), a Dhaka-based non-governmental organisation (NGO), revealed that about 90 per cent of Hazaribag tannery workers die before reaching the age of 50 due to unhygienic working conditions. About 58.10 per cent of workers suffer from


ulcers while 31.28 per cent have skin diseases (Bangladesh National Report 1996–2001).

The review of literature also suggests that the relationship between water and health is not linear. There are various socio-economic, cultural and political factors, which determine the status of water and health. Section 3.0 discusses major complexities and challenges faced by the South Asian region in this sector.

CHALLENGES IN PROVIDING ACCESS TO WATER AND HEALTH IN SOUTH ASIA

South Asia has been a water-scarce region, especially the arid and semi-arid areas. Rapid urbanisation, population pressure and indus-trial development have aggravated the problem in recent years. The three prominent sectors—domestic, agriculture and industry—now routinely vie for the same limited water supplies. Irrigation water, once the preserve of farmers, is now often tapped to supply to industryand urban areas because new water systems are costly to develop. Estimates suggest that by 2025, the amount of water needed to meet demands in South Asia is expected to double, while the water going to industry and energy generation is expected to triple. Municipal and industrial use of water will account for 27 per cent of total with-drawals in India by 2025, compared to 17 per cent in the mid-1990s (Meinzen-Dick 2005).

Similar trends are evident in other parts of South Asia indicating that the domestic water sector will have to compete with other sec-tors, which is largely the case even now in many locations. These competitions are going to be starker in the near future, leading to major water-related health implications. The brunt of this process will definitely be borne by people living on the margins of society, who need access to safe water to maintain health and lead a productive life to sustain livelihoods.

Challenges in Accessing Safe Water

The first challenge related to water supply is coverage. Water supply coverage figures of South Asia (Table 3.1) show that it is on track


as far as MDG targets are concerned (WHO–UNICEF JMP 2008). However, most of the coverage figures are calculated based on the existence of an infrastructure and that does not necessarily show whether water is accessible to people or not. Issues of water quality and groundwater depletion have much to contribute in providing lack of access to drinking water. Water quality is emerging as a major concern and greater emphasis needs to be placed on making safe water available at the points of source as well as consumption. Apart from developing infrastructure for safe water supply, maintenance of existing infrastructure is also a challenge. There are no proper mech-anisms to monitor water quality in the distribution system. Processes for ensuring regular testing of water quality and working out the institutions responsible for doing this, and mechanisms for holding these institutions accountable are not yet in place.

Due to surface water getting more and more polluted, groundwater is seen as an alternate source of safe water supply. Most of the do-mestic water supply in South Asia is based on groundwater. In India, roughly 80 per cent of rural water supply for domestic use is met from groundwater (Tripathi 2000). Groundwater provides 50 per cent of the present water supply in Kathmandu and abstraction from both shallow and deep aquifers (Upadhyaya et al. undated). Groundwater sources in the vicinity free people, particularly women, from travelling long distances to collect water. This provides them with adequate time for other activities. Furthermore, as water no longer needs to be carried over long distances, more quantity is consumed. This leads to major health benefits. However, groundwater depletion due to overdraft, water logging and salinisation, mostly due to inadequate drainage and insufficient conjunctive use, as well as pollution due to agricultural, industrial and other human activities, will accentuate the problem of access to drinking water for the poor and marginalised. Decentralisation of water quality monitoring at community level needs to be institutionalised and this demands capacity building at all levels (Srikanth 2009).

Challenges in Managing Wastewater

Most cities in South Asia do not have proper wastewater treatment plans. Each user not only takes water out, but also puts something


back into the water supply, such as agrochemicals, municipal wastes or industrial effluents. Very little municipal sewage in South Asiais treated. The Noyyal Basin in Tamil Nadu, India, for example, has become a ‘dead river’ because of discharges from textile factories and over 10,000 acres of irrigated area have become unproductive (Banerjee 2002).

Challenges of Providing Safe Sanitation

Achieving sanitation for all remains a distant dream in South Asia. The region had just 52 per cent sanitation coverage in 2006 compared to 72 per cent in sub-Saharan Africa and 82 per cent in South-Eastern Asia. Country-specific figures show that countries of South Asia, namely Bangladesh, India and Pakistan, have millions of people who are still without access to safe water and adequate sanitation. The growing economy of South Asia also brings contradictions of development in terms of number of people living below the poverty line and water and sanitation coverage. These figures tell a bleak tale despite claims of significant investments over the last 20 years. As a result, South Asia will miss the MDG target (WHO–UNICEF JMP 2008). The rapid urbanisation in the region is putting strain on the already stressed urban sanitation systems. Slums are very rarely con-nected to sanitation infrastructure of cities and the sanitation situation in slums is deplorable.

The emphasis to meet national and international coverage targets has led to construction of latrines only. The so called latrinisation, while implementing ‘total sanitation’ has taken a back seat. Based on the number of latrines constructed, communities are being declared ‘totally sanitised’. There is absence of monitoring on the use of household latrines, hand washing and other hygiene practices and also provision of latrines in schools and public places. The existing monitoring systems focus on just counting latrines and do not provide information on the number of totally sanitized communities and, most importantly, sustainability (WaterAid 2006). Financing sani-tation facilities also poses major challenges. In national budgets of most countries, allocation for water and sanitation are combined, leading


to priority being given to water supply projects, whereas sanitation is ignored (Pramanik 2007).

Challenge of Health Sector

Regardless of diverse geographical, linguistic and political structures, Afghanistan, Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan and Sri Lanka face common health challenges (Sadana et al. 2004). Healthcare services in South Asia, including both traditional and modern systems, are delivered by public and private sectors and non-government welfare organisations. Although, all countries in this region have shown their commitment to achieve ‘Health for All’ by signing the Alma Ata declaration, the achievements are few and the progress is slow mainly due to poor execution of national policies and programmes, lack of a monitoring system for environmental health concerns, inadequate budget, insufficient health infrastructure and trained manpower, inequity, gender insensitivity and lack of proper health education. Some of the major challenges are discussed below.

Inadequate Health Financing and InequalitiesTotal expenditure on health in South Asia is one of the lowest in the world. The average per capita total expenditure per year on health from all sources—public, private and foreign aid—was just USD 31.75 in 2003. Government expenditure is often very low. For example, per capita government expenditure on health in 2003 was just USD 4 per person in Bangladesh; USD 4 in Pakistan; USD 3 in Nepal; USD 4 in Afghanistan; USD 14 in Sri Lanka; USD 9 in Bhutan; and USD 7 in India, with the exception of Maldives, where per capita investment (USD 121) was much higher (WHO 2006). The meager amount spent by the government often benefits urban or wealthier people (Schäfer-Preuss 2009).

Inadequate budget for health leads to poor public health infra-structure and insufficient trained human resources. To illustrate, due to inadequate budget and pressure to achieve targets, several states upgraded two-room sub-centres to full Public Health Centres (PHCs). With limited space for a laboratory, examinations, pharmacy, and so onmany are not fully functional (WHO 2007). Outof pocket private


expenditure is often very high, with implications for equity and im-poverishment. In Bangladesh, Nepal, India and Pakistan, about 70 per cent of total expenditure on health comes ‘out of pocket’(WHO 2008). Even such small payments can be a barrier to essential health care for poor people, and often become a source of increasing inequality and impoverishment. For example, a recent ADB study found that about 40 million people in India fell below the poverty line due to health payments (Schäfer-Preuss 2009).

Shortages in Human Resources for HealthThe most serious challenge which remains in South Asia today is human resources for health. One need not go far to understand this situation. Just look at the new government initiatives such as the National Rural Health Mission which are launched in India and the glaringly visible shortage of trained health personnel in several cat-egories and at multiple levels. From accredited social health activists (ASHAs) to Anganwadi workers or from multi-purpose health workersto people involved in vector control, the call of the hour is both quan-tity and quality of human power. Also, restricted capacity for research in the public health domain and weak supervisory and surveillance systems lead to serious information gaps leading to hurdles in policy implementation, thus jeopardising the very existence of public health programs (Reddy 2007). Bangladesh has also been identified as one of the countries in South Asia where ‘severe shortage’ of health workers exists. Due to this, most of the poor and disadvantaged seek health care from non-qualified health care providers operating in the informal sector (Ahmed et al. 2011).

Health Education and Behavioural FactorsApart from efficient public health services, individual behaviour plays a significant role in preventing and controlling health related prob-lems. These behavioural practices include personal hygiene, proper storage of water, and so on. Health education can play an important role in inculcating such behaviour during the formative years of an individual. But as access to education for the poor, both in urban and rural areas, is still a challenge, percolation of such behaviour is disappointedly slow.


Systemic Complexities, Missing Inter-linkages and Need for Inter-sectoral Coordination

Public health mainly depends on many factors such as adequate nutri-tion, safe drinking water, sanitation, housing, clean environment, primary education and social equity, all of which are interconnected. Bringing down the burden of water-borne diseases calls for the conflu-ence of health, water, environment and development policies towards a common goal. It needs inter-disciplinary understanding and multi-sectoral action. However, before addressing inter- or multi-sectoral integration, the primary task should be eventually to ensure integration within the sectors. If we look at the water sector, the responsibility for managing the water resources is often fragmented across different sectors and levels of decision. This is the major obstacle in designing and implementing effective preventive health policies in this field. The key challenge is to bring in human health as a cross-cutting issue throughout decision-making in different sectors and at different levels. The promotion of Integrated Water Resources Management (IWRM) is seen as a remedy to include a health component into water resources projects (WHO 2003).

Similar to the water sector, the health sector is also organisation-ally complex, adding to systemic chaos. In majority of developing countries, the Ministry of Health (MoH) is the primary governing body and is responsible for all aspects of policymaking, planning, regulation, monitoring and evaluation and also for ensuring access to basic and essential health services. The implementation part comes under the jurisdiction of sub-national—state, provincial, district or local—governments (Siddiqi et al. 2009). Additionally, it has also been observed that in a majority of cases, allocation of water for drinking and sanitation; water quality control and monitoring; and development and maintenance of infrastructure for supply are under the purview of other agencies and not health agencies, resulting in these aspects being ignored in high level health policy discussions (Bliss 2009).

To illustrate this, in Maharashtra, a state of India, in spite of health investments, infectious diseases emerged due to lack of provisions of drinking water, failure in monitoring chlorination of water and


maintenance of water supply, sewerage, sanitation and other related infrastructures (Saxena 2007). The 1996 Expert Committee on Public Health System (Bajaj Committee) has recommended inter-sectoral cooperation for the betterment of health services in India, and sug-gested setting up of two coordinating committees, namely cabinet committee on health and committee of secretaries, chaired by cabinet secretary comprising all departments concerned with activities influ-encing health outcomes like education, sanitation, drinking water, environment, nutrition, and so on (WHO 2005).

There is a need for policies to be inter-related. The model ofpublic health system adopted in Sri Lanka is inspirational.5 An alternative governance structure is required with more emphasis on decentralisation.

CONCLUSIONS AND THE WAY FORWARD For the South Asian region, which is already struggling to cope with exponentially growing scarcity of water, providing safe water has become a real public health challenge. Given the rapid rate of growth in the industrial and agricultural sectors along with an ever-increasingpopulation and a burgeoning section following an industrialised lifestyle, the pressure to provide adequate water from limited sources

5 During the last decades, Sri Lanka has shown tremendous improvement in providing safe drinking water to its people. The Ministry of Health is not directly responsible for provision of water. Health education is implemented through its field health personnel, namely motivating people to consume boiled cooled water, which is usually considered safe. Government functionaries, namely the Public Health Inspectors (PHIs) conduct routine tests for adequate chlorination of drinking water sources during epidemics of bowel diseases, like diarrhoea and gastro-enteritis and disaster situations like floods, and so on. The health authorities ensure that there is no contamination of drinking water sources from toilets and other sources, before approving applications for construction of buildings. The use of latrines by com-munities is also promoted (including enforcement of provisions of relevant legislation related to housing). It is mandatory for all new houses to process toilet facilities in order to obtain approval from local authorities. Additionally, the department of health services provides financial assistance to those who are unable to construct toilets due to limited resources (WHO 2005).


is intense. Although countries seem to have worked on the Millennium Development Goals (MDGs) to create infrastructure concerning water supply and sanitation, it is still questionable whether these measures have led to increased access to adequate safe water supply and propersanitation at all. Also, has the concept of hygiene been imbibed by individuals/communities? The existing literature provides sufficient evidence of very high burden of preventable water-related diseases in South Asian countries. Though countries have progressed in con-trolling these diseases, achievements have been limited. This failure can be attributed to lack of a holistic approach while formulating policies and implementing programmes for strengthening public health system.

The way forward for these countries is to revisit their existing strategies, to reform their governance structure and adopt a more integrated and demand-driven approach by appreciating proven water and health linkages along with other governing factors such as socio-economic, environmental and political to conquer water-related health hazards. Figure 2.1 presents a framework for ‘good governance’ for integrating water and health. The proposed framework adopts two main strategies that integrate health perspective and water resources management and also bring in provision of safe and adequate water and sanitation into the mainstream public health system. It follows United Nation’s (UN) conceptual framework of good governance (UNESCAP undated) defining it as participatory, consensus oriented, accountable, transparent, responsive, effective and efficient, equitable and inclusive, and follows the rule of law. It aims to ensure intra- as well as inter-sectoral integration, both vertically and horizontally, and seeks involvement on all the three spheres of society, that is state, market and civil society, at every level of decision making. It advocates a national level body to co-ordinate and monitor the entire process of integration.

However, for ‘good governance for water and health’ being a success in South Asia, it would require path-breaking and radical changes in the prevailing policy frameworks. It is also imperative to mention that overall governance of the country will have a telling influence on the performance of this new system.

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———. 2005. ‘Sri Lanka National Health System Profile – January 2005’. Available online at http://www.searo.who.int/LinkFiles/Sri_lanka_CountryHealthSys-temProfile-SriLanka-Jan2005.pdf. Downloaded on 12 April 2009.

———. 2006. World Health Report 2006: Working Together for Health. Geneva: World Health Organization. Available online at http://www.who.int/whr/2006/whr06_en.pdf. Downloaded on 10 May 2009.

———. 2007. Country Health Profile: India. Available online at http://www.searo.who.int/LinkFiles/Country_Health_System_Profile_4-India.pdf. Downloaded on 12 April 2009.

———. 2008. World Health Statistics, 2008. Geneva: World Health Organization, pp. 84–85.

WHO–UNICEF JMP. 2008. WHO–UNICEF Joint Monitoring Programme (JMP) for Water Supply and Sanitation. Available oline at http://www.wssinfo.org/en/welcome.html. Downloaded on 12 September 2009.

World Bank. 2005. Towards a More Effective Operational Response: Arsenic Con-tamination of Groundwater in South and East Asian Countries. Vol. I. (Report No. 31303). Washington, D.C.: The World Bank and New Delhi: Water and Sanitation Program—South Asia.

3

Water, Health and Poverty in South Asia

Examining the Interface in India

AMITA SHAH AND SAJITHA O.G.

The availability of water is a concern for some countries. But the scarcity at the heart of the global water crisis is rooted in power, poverty, and

inequality, not physical availability. (UNDP 2006)

INTRODUCTION

SOUTH ASIA HAS emerged as one of the fastest growing regions of the world. Home to nearly 44 per cent of the world’s poor who live with less than one US dollar a day (Bell and Goonesekere 2000), the absence of adequate quantity of quality water is by far the most serious crisis faced by a signifi cantly large proportion of population in this region. This crisis has a direct bearing on health, one of the most important dimensions of human well-being. It exerts a strong negative impact on economic growth and poverty across countries in the region (Shah 2008). Whereas the link between water and human health is fairly clear and explicit as it manifests through higher mor-bidity, mortality and malnutrition, especially among children, the link between ill-health and poverty is relatively less understood (Mallik 2006). Since health–poverty interface, unlike water–health linkages, operate at both macro as well as micro levels, ascertaining the linkage is somewhat complex (Bloom et al. 2001).

Ill-health is both a cause as well as a result of poverty, and it has directas well as indirect infl uence on the productive capacities and actual productivity of the labour force within the economy (Abayawardana S. and Hussain I 2002). The estimates based on a global model indi-cate that the cost of water defi cit for drinking and sanitation amounts

50 Amita Shah and Sajitha O.G.

to $170 billion, which accounts for about 2.6 per cent of the gross domestic product (GDP) of the developing economies in differentparts of the world (UNDP 2006). In 2004, nearly 229 million people in South Asia did not have access to improved drinking water(UNDP 2006). It is thus imperative to note that the Millennium Developmental Goals (MDGs) pertaining to drinking water, child mortality and poverty are not perceived as independent endeavours; rather these goals are closely inter-related as attainment of one of these MDGs is expected to promote the other two (MUHHDC 2006).

About 30 per cent people in South Asia live on one US dollar per day, and another 17 per cent live with an income of $1 or 2 a day (Ravallion et al. 2008). The region has disproportionate share in the poor population of the world. Whereas South Asia is home to about one-fi fth of the world’s population, its share in the global incomeis only 7 per cent (MUHHDC 2006). A vast majority of the poor, besides many not-so-poor in the region, are victims of water-related diseases emanating from inadequate and/or poor quality drinking water. While the former leads to malnourishment, thereby making the population highly vulnerable to other ailments, the latter exerts more direct impact through high incidence of morbidity and mortality. Children are the most frequent victims of these diseases that manifest as a high mortality rate in the region and also as reduced lifetime cap-abilities among those who survive. Nearly 3.4 million people, mostly children, die annually of water-related diseases (Brudtland 2001). Recent estimates show that child deaths due to diarrhoea itself were 1.6 million (UNICEF 2007).

This chapter consists of four main sections dealing with the context and presenting a broad overview of the extent of water-related diseases in India; a brief profi le of the three components in the Indian context; an examination of the correlation among them across major states in India and analysing determinants of morbidity using household level data; and fi nally discussing the evolution of policies in the country.

NEGLECT IN POLICY FRAMEWORK

In India, about 30.5 million Disability Adjusted Life Years (DALYs) are lost each year due to poor quality water, sanitation and hygiene. The World Health Organization (WHO) has identifi ed about 25

Water, Health and Poverty in South Asia 51

diseases—including diarrhoea, malaria, avian infl uenza; ailments resulting from high contents of arsenic and fl uoride in water; and anaemia and malnutrition—that could be considered as water-related ailments (WHO 2000).

Water-related diseases mainly occur through transmission of pathogens from drinking water or via faecal–oral route or due to directcontact with contaminated water. Some zoonotic pathogens can survive for months and some others are able to re-grow in the envir-onment resulting in higher probability of waterborne transmission. Mitigation of health risks is possible through protection of water source, treatment of water and point of use and other interventions involving both techno-economic and socio-cultural solutions.

SYSTEMIC APPROACH CAN WORK

Despite the fairly clear link between access to safe and adequatequantity of drinking water and human well-being, the domestic sector in water resources has failed to receive the deserved priority in terms of resource allocation, technical support and institutional back-up essential for ensuring ‘water security for all’. In most developing eco-nomies, including those of South Asia, the issue has been limited to that of only supplying water to rural and urban communities, irrespectiveof quality and sustainability of the water source. India, with the vast land mass, diverse ecological conditions and a large population with high incidence of poverty, is a glaring example of the nexus between water, ill-health and poverty.

Provision of safe drinking water to all necessitates more systemic than individual solutions. Scarcity of water resources, low level of awareness and limited paying capacity among a large proportion of the poor reinforce the criticality of systematic solutions. This involves a comprehensive approach consisting of water augmentation and management, awareness generation and institutional mechanisms for benefi t-sharing and fi nancial viability. Community participation becomes an important element in this context. In a major policy pronouncement, the Government of India has reiterated its commit-ment to ensure ‘water for all’ while formulating the 11th Five Year Plan.However, a comprehensive strategy is still not in place. Even though studies focusing on South Asian countries, including India, have


highlighted the need for moving towards a comprehensive approach for water resource management, there are a number of challenges—fi nancial, administrative, and above all, political—that are yet to be addressed adequately.

A clear understanding, based on empirical analysis of the interface between scarcity of potable water, health hazards and poverty may help policy formulation process, thereby breaking the deadlock on shifting towards a comprehensive policy on water for all. This would be of great help in a region that has high incidence of poverty.

DATA AND METHODOLOGY The empirical analysis for the case study of India is based on secondary data pertaining to the indicators mentioned at the state and household level. The initial mapping of morbidity has been carried out with the help of the National Sample Survey Organisation (NSSO) morbidity data for the year 2004, the National Family Health Survey-3 (NFHS) (2005–2006) and other secondary sources. An analysis of causality of ill-health has also been done by using household level information from the two national surveys mentioned above. The NFHS provides data for prevalence of diarrhoea (for two-week period) and blood sample tests of the haemoglobin levels for women and men in the age group 15–49. However, it lacks information on other water related diseases at the household level. Hence, this research used unit level data of NSSO to study the hazards due to any water related diseases in the household. The interface between water, health and poverty has been examined through correlations between various indicators for the major states in India. Whereas the state level analysis is aimed at identifying broad patterns across the regions, the household level exercise focuses on examining the causality by using analysis of hazard function.

IMPACT OF WATER AND ILL-HEALTH ON ECONOMIC GROWTH AND POVERTY IN INDIA

India is home to about one-third of the poor (Himanshu 2008) and accounts for one-third of the diarrhoea cases in the world (GoI 2005).


It also suffers from severe water scarcity with nearly 50 per cent of its land mass under arid, semi arid and tropics conditions (Ravallion 2008)Besides the intrinsic value of health for human well-being, policy framework in India of late has started recognising strategic signifi cance of good health from the view point of growth and poverty reduction. The recently published Report of Macro Economics and Health says that ‘the unpredictability of illness requiring substantial amount of money at short notice is impoverishing 3.3 per cent of India’s popu-lation every year’ (GoI 2005). The cost of DALYs is estimated to be about ` 36 million). A more recent study (Dev et al. 2007), based on a large survey covering 9 districts in three states, Orissa, Madhya Pradesh and Karnataka revealed that sudden health problems were the most important risk impacting 20 per cent of rural households. The study also found that the health risk is signifi cantly higher among the poor.

Lack of adequate and safe drinking water has been long recognised as the most important barrier causing ill-health and malnutrition among a large proportion of India’s population. The debates onmalnutrition during the early 1960s had underlined the importance of safe drinking water by highlighting its critical role in the conversion effi ciency of food into energy. Also, control of communicable dis-eases and improvement in healthcare could signifi cantly reduce foodwastages caused by diarrhoea and dysentery (Seckler 1982).

These estimates, though scattered, have led to clearly recognising the urgency of providing safe drinking water, along with sanitation and clean environment, for improving health of the people and reducing incidence of diseases and deaths among policymakers in India (GoI 2008).

POVERTY, ACCESS TO WATER AND BURDEN OFDISEASES IN INDIA

A macro picture of selected indicators pertaining to the three broad parameters covered in this chapter has been presented in Table 3.1. A brief profi le of the three components in Indian context is presented.


A DAUNTING CHALLENGE With nearly 320 million people living below the offi cial poverty line, poverty is one of the most daunting challenges facing policymakers in this country. In fact, the proportion of people living in poverty or with multiple deprivations is signifi cantly larger than offi cially estimated.A number of issues have been raised with respect to underestimation of poverty in India. The most critical issue is that of calorie gap, which indicates that the food basket actually consumed by individuals does not provide enough calories to meet the normative requirement (that is2,100 per capita per day in urban areas and 2,400 in rural areas) among households. Highlighting the glaring calorie gap, Patnaik (2007) argues that 87 per cent of India’s rural population does not consume enough or right combination of food to meet the normativerequirements of calories; and even if one considers a lower norm of 2,200 calories per capita per day, nearly 70 per cent of the rural popu-lation still experience the calorie gap.

Table 3.1: Profi le of Poverty, Health and Water in India

Sr. No.

Indicators(Year) Value

1 Poverty Head Count Ratio (2004–05) 27.52 Nutritional defi ciency

a) Undernourishment among children (2002) b) Chronic energy defi ciency – adult male Chronic energy defi ciency – adult female

47. 8%37.4%39.4%

3 Life expectancy (2001) 66 years4 Infant mortality (2005−06) 58/1000 live births5 Expenditure on health (% to Total HHS

expenditure) (2004−05)5.9

6 % of rural habitations accessing improved sources of drinking water (2007)

90

7 % of HHS with toilet facility (2007) 498 % of area and population facing problems of

arsenic and fl uoride (2000)Arsenic – 13.8 million in 17 blocks; Fluoride – 66 million across 17 states

Source: GoI (2008).Note: Head Count Ratio is an offi cial measure of poverty in India. This is based

on the poverty line per capita consumption expenditure deemed as required for the individuals to purchase food and other basic items so as to be able to meet the stipulated calorie intake.


Undernourishment is a fairly widespread phenomenon in India, covering nearly 48 per cent of children under the age of three years. This consists of 18.4 per cent as severely undernourished and 29.4 as moderately undernourished. About 37−39 per cent of the population is suffering from chronic energy defi ciency. It is, therefore, argued that whereas food-based interventions could play a supplementary role, pro-poor growth alone can eliminate chronic food inadequacy in the long run (Radhakrishna 2005). This is important considering that food inadequacy outpaces income/expenditure. Hence, increase in income per se is crucial for addressing the issue of food inadequacy. In this context, the increasing (private) cost of health services emerges as an important factor in forcing non-poor households into poverty. According to a study by Dev and Ravi (2007), the poverty ratio goes up to nearly 34−36 per cent if one takes into account the actual ex-penditure on health and education while estimating the poor.

WHY SAFE DRINKING WATER IS NOT AVAILABLE

According to offi cial estimates, nearly 90 per cent of the 15.07 lakh (1.507 million) rural habitations in the country were covered by im-proved water sources. Of these, about 75 per cent were fully covered while the remaining 15 per cent were partially covered (GoI 2008). While this is quite impressive, the ground reality is not that encouraging as a large proportion of the habitations that have improved sources of drinking water tend to slip back into the category of non-covered areas. According to the Planning Commission (GoI 2002) an estimated0.2 million of the fully covered rural habitations had problems of quality of water and 60,000 habitations had faced problems of salinity,arsenic or fl uoride contamination. A large number of fully- or partially-covered habitations often faced water scarcity, especially during the summer season and also during droughts that hit nearly two-thirds of India’s land mass, almost two or three times in a cycle of fi ve years.

The scenario in urban areas is equally worrisome. While more than 90 per cent of the urban population is served through water supply schemes, the issues of adequacy and equity do not get addressed. The average availability of drinking water, as compared to the norms, is found to be positively associated with the size of the urban settlements, ranging from 73 to 58 per cent in towns (73, 63, 61 and 58 per cent


in class 1, class II, class III and other towns, respectively. Slumdwellers are often deprived of access from such schemes (GoI 2008).

Excessive dependence on groundwater as a major source of water supply, combined with rapidly depleting groundwater table owing to aggressive and competitive use of water for agriculture, and at times, for urban industrial uses, are important factors infl uencing the de-velopment of safe and adequate sources for drinking water.

MORBIDITY: WHAT NSSO EVIDENCE SUGGESTS

NSSO in its 60th survey provided estimates of morbidity among households based on the type of ailments for 2004−05. This infor-mation pertains to the reported morbidity for a reference period of15 days during a year. It appears that practice of reporting on morbidity is generally low in developing economies with low literacy, awareness and perhaps aspirations. As a result, only a fraction of the people who suffer from some ailment actually report about it. This is refl ected by the fact that the proportion of people reported to have morbidity during 2004−05 is estimated to be only about 10 per cent of the total population. Of these, 10.2 per cent cases refer to water related mor-bidity whereas more than three-fourths refer to ailments generally viewed as ‘lifestyle’ related (see Figure 3.1). It is observed that the pro-portion of people reporting ‘lifestyle’ type of morbidity (cardiovascular disorder, tuberculosis, fever, and so on) increases along the monthly per capita expenditure (MPCE)-quintile. Overall, 13.6 per cent of the population in the highest quintile reported any kind of morbidity as compared to 6.9 per cent among the lowest MPCE-quintile.

Children and old persons, especially from poor households, con-stitute the most vulnerable group with high burden of water related diseases.

Residential location is important in the morbidity discourse owing to the inequitable distribution of knowledge—human resources−and infrastructure for drinking water supply and healthcare system across rural and urban areas. In India, more than 70 per cent of medical doctorsare practising in urban areas whereas 70 per cent of the population live in rural areas. The water-related morbidity is observed as 11 per 1,000 rural people against 9 per 1,000 urban people. The chi square value for


Figure 3.1: Percentage of Population Reporting Morbidity by Monthly Per Capita Consumption Expenditure

Source: Calculated from unit level data of NSSO 60th round survey on Health and Morbidity.

the relationship was 38.75 (p> .000). However, after controlling for quality of drinking water and levels of income, the differences in rural–urban morbidity is found to be fairly clear. Strangely, inci-dence of morbidity is found to be lower among females compared to males, especially among the lower income/expenditure quintile (Table 3.2).

ANAEMIA, DIARRHOEA AND WATER PURIFICATION

The NFHS 2005–06 provides information about prevalence of an-aemia and specifi c morbidity. Information regarding specifi c morbidity


Table 3.2: Percentage with Low Body Mass Index (BMI) and Anaemia for Women and Men in the Age Group 15–49 with Background Characteristics, India 2005–06

BMI below Normal∗ Anaemia∗∗

Women Men Women Men

Age 15–19 46.8 58.1 55.8 30.220–29 38.1 33 56.1 19.330–39 31 25.5 54.2 23.140–49 26.4 26.2 55 27.9Place of Residence Urban 25 26.5 50.9 17.7Rural 40.6 38.4 57.4 27.7Education Illiterate 41.7 40.3 60.1 33.7<5 years 37.2 37.5 58.1 30.45–7 years 34.1 38.6 56 25.88–9 years 35 39.5 52.4 23.710–11 years 29.4 31.6 49.2 19.612 or more 21.8 19.3 44.6 14.8Caste/tribe SC 41.1 39.1 58.3 26.6ST 46.6 41.3 68.5 39.6OBC 35.7 34.6 54.4 22.3Other 29.4 28.9 51.3 20.9Wealth Index 24.8Lowest 51.5 48.3 64.3 37.9Second 46.3 42.4 60.3 30.2Middle 38.3 37.4 56 24.8Fourth 28.9 29.6 52.2 18.8Highest 18.2 19.1 46.1 14.2Total 35.6 34.2 55.3 24.2

Source: National Family Health Survey-3 (2005–06). ∗ BMI value <18.5 kg/m2 for both sexes . ∗∗ Haemoglobin level for women <12.0 g/dl and 13.g/dl for men.

(malaria, diarrhoea) is obtained by recall for a period of 15 days and that for anaemia is collected through actual pathological tests. Accordingthe available estimates, nearly 56.2 per cent of women were found to be anaemic compared to 24.7 per cent of men and 69.5 per cent of children. Similarly, the incidence of diarrhoea is found to be around 9 per cent of the country’s population.


Table 3.2 presents status of prevalence of body mass index (PBMI) and anaemia by some of the important socio-economic character-istics among men and women. It is observed that the difference in PBMI between women and men in the age group 15−49 is quite less (35.6 per cent and 34.2 per cent respectively). But the Haemoglobin tests identifi ed very high differences in the anaemia levels between women and men (55.3 per cent and 24.2 per cent). Moreover, anaemialevel is found to be varying depending on residence, education and caste of both the sexes. Anaemia is found to be very high among households belonging to rural areas, scheduled tribes as well as among illiterates.

Table 3.3 presents distribution of households based on waterpurifi cation method and income levels. It is observed that 73 per cent of the households do not purify water. The proportion is 87 per cent among households in the lowest income quintile, whereas it is 52 per cent among the highest income quintile. This suggests that relatively poorer households are vulnerable to more drinking water pollution than the richer groups. However, once exposed, the impact in terms of morbidity is more or less the same as discussed later in this chapter.

Table 3.3: Quality of Water Used by Income Groups

Method of Purifi cation

IncomeQ1

IncomeQ2

IncomeQ3

IncomeQ4

IncomeQ5 Total

Boiling/RO/disinfectant

N 3229 5855 9663 14978 27617 61342% 4.30 7.43 12.84 19.07 36.11 15.97

Cloth stainingN 6516 7994 8491 9526 9082 41609% 8.68 10.15 11.29 12.13 11.87 10.83

NothingN 65283 64922 57086 54032 39790 281113% 87.01 82.42 75.87 68.80 52.02 73.19

Total N 75028 78771 75240 78536 76489 384064 % 100 100 100 100 100 100

Source: National Family Health Survey–3 (2005–06).Note: Q1–Q5 denote households across per capita expenditure quintile.

To what extent are water related diseases such as anaemia connected to the quality of water? This aspect has been examined in the light of the type of water purifi cation process followed by various income groups. Figure 3.2 shows the prevalence of anaemia among women and men with respect to the type of sterilisation process followed for drinking water.


It is evident that anaemia levels were very low among those using electric water purifi ers. Most of these households are likely to be in the category of higher economic strata. Only 11.36 per cent of men and 40.73 per cent of women in that category were found to be anaemic. Similar pattern is observed in case of other methods of purifi cation, such as adding bleach or chlorine to water or boiling thewater. However, the difference among households using some method of purifi cation and those not using any of the listed purifi cation methods is relatively smaller compared to the difference between households using electronic method and those not using any method. Electronic purifi ers not only eliminate bacteria or pesticides but also reduce dissolved minerals and pollutants. The reverse osmosis (RO) in the systems also maintains the desired levels of elements in the water. Thus, compared to high household income or higher educa-tion, the two parameters which can reduce the chances of morbidity and the incidence of anaemia it is found to be low among those using water purifi ed using electric purifi ers. It also highlights the fact that besides eliminating living pathogens by boiling the contaminated water, maintaining adequate levels of minerals in drinking water is also important in reducing anaemia. These observations are, however,

Figure 3.2: Anaemia among Women and Men in the Age Group 15–49 by the Type of Drinking Water

Source: Calculated from unit level data of NFHS–3.


subject to the ambiguity in data pertaining to purifi cation of water, especially in urban areas.

INCIDENCE AND THE INTERFACE:A STATE LEVEL ANALYSIS

The foregoing evidence indicates close inter-linkages between the three sets of parameters, namely poverty, health and water. Examining the correlation among 15 variables representing the three important parameters brought out some important observations. It was found that the poverty ratio has signifi cant positive correlation with most ofthe indicators of ill-health, except diarrhoea. Poverty is also negatively associated with median years of school among men and women. Moreover, poverty ratio has negative correlation with infrastructural indicators like percentage of households with electricity and toilets. What is, however, noteworthy is that the link between poverty and access to safe and/or improved sources of water is not found to be signifi cant. The results also indicated that prevalence of diarrhoea is positively associated with infant and child mortality. This observa-tion is further substantiated by the fact that high quality drinking water has negative association with anaemia among men and children(at 10 per cent level), but not among women. Similarly, quality of drinking water has negative association with irrigation suggesting importance of water resource endowment in a state. Overall, the results indicated a mixed picture, though it confi rmed the expected close links between poverty and most of the indicators of ill-health across major states in India.

IMPACT OF WATER PURIFICATION METHODACROSS INCOME LEVELS

In order to confi rm the signifi cance of the hypothesis that if the water-related diseases are related to the quality of drinking water, morbidity will be lower with drinking safe water, we took Cox-proportional Regression Model with water-related diseases as the dependent and type of drinking water as the covariate with change of period as the lowest to the highest income.


Table 3.4 shows the actual reduction in health hazard with safe drinking water over the higher quintiles of wealth. It is observed that compared to those drinking boiled/purifi ed water, probability of hazard due to water related diseases was 78 per cent higher among those who were using a piece of cloth to strain the water. Similarly, the chances of morbidity among people who were drinking non-treated water were 84 per cent higher compared to those who were drinking treated water.

Table 3.4: Impact of Different Water Purifi cation Methods on WRM across Wealth Quintiles

Odds Signifi cant

Water TtreatmentBoiling/RO/disinfectant 1.000Straining with cloth 1.786 0.000No purifi cation 1.844 0.000

Source: Estimated from unit level data, NSSO (2006).

The analysis leads to two important fi ndings. First, incidence of morbidity due to water-related diseases is higher among higher income groups, while there is high water-related mortality among lower income groups. Second, accessing safe drinking water by using proper methods such as boiling or other electronic methods reduces the incidence of diseases irrespective of income.

EMERGING POLICY PERSPECTIVES

India is a home to about one-third of the poor (Himanshu 2008) and accounts for one-third of diarrhoea cases in the world (GoI 2005). It also suffers from severe water scarcity with nearly 50 per cent of its land mass under arid, semi-arid and tropical conditions (Ravallion 2008).

The analysis of the linkages between water, health and poverty reinstate strong inter-dependence where the three components workin a mutually reinforcing manner. This implies simultaneously strengthening all the three components to obtain robust outcomes in terms of improved health and human well-being, besides economic


growth. The inter-dependence, however, poses the challenge of identi-fying the strategic intervention that may trigger a series of positive changes encompassing all the three components.

It may be appropriate, in this context, to stress on the primacy of water-access as a lead component to spearhead a process of change. The underlying rationale emanates from the critical importance of adequate quantity of and good quality of water for sustaining the very existence ofhuman life. The need, therefore, is to start with fulfi llment of the agenda of ‘water for all’, which in turn would feed into better health and better economic conditions even among those with limited access to productive assets and/or employment in the initial period.

Since the start of planned development in India in 1950, policy for drinking water and sanitation has been envisaged as an integral part of the health sector. The fi rst National Water Supply Programme was launched in 1954 as part of the health sector plan, with equal funding by the central and state governments. The plan emphasised on supply of piped water to rural households. The initial emphasis was on developing local sources which gradually had to be diluted given the increased scarcity and pollution of groundwater. This for the fi rst time opened up avenues for promoting community-based (if notcommunity-led) initiatives for augmentation and supply of drinking water among rural habitations (GoI 2002). The focus, however, continued to be supply-driven, devoid of the sustainability aspect of resource augmentation. During this time, transfer of the bulk of water became almost inevitable, which necessitated the state to assume full responsibility of providing water to all population in the country (Hirway and Lodhia 2007). The subsequent plans made fi nancial allocations for strengthening the health engineering departments at the state level. In 1968, the state governments were authorised to sanction rural water schemes subject to the defi ned limits.

The late 1980s witnessed emergence of a crisis situation, triggered primarily by frequent droughts and ceaseless use of groundwater for agriculture in the absence of a comprehensive planning for water resource development and management. Shifting to a ‘demand-led’ approach, therefore, was seen as a solution to address the crisis. This in turn brought in the new framework of ‘sector reforms’ with user contribution, community participation and resource augmentation


as the central elements. Unfortunately, both the supply as well as demand-led approaches did not deal with the critical issues of resource management, namely equity, sustainability and decentralised gov-ernance. At the same time, recent policy initiatives on water resource development have upheld the priority of drinking water whileallocating the resources for various uses. Table 3.5 presents some of the major landmarks in the evolution of policy initiatives for drinking water supply. During this evolution, sanitation got increasing emphasis and was better integrated with water resource management.

Table 3.5: Evolution of Drinking Water Supply Policies in India

Year Major Policy Initiatives Details

1954 National Water Supply Programme

As part of the health sector initiatives

1968 Rural Water Supply Scheme Focus on piped water1972–73 Accelerated Rural Water

Supply ProgrammeMission mode

1991–92 Rajiv Gandhi NationalDrinking Water Mission

Renaming of Accelerated Rural Water Supply Programme

1999 Setting up of the Department of Drinking Water Supply in the Ministry of Rural Development (MoRD),Govt. of India

Added focus on sanitation

1999 Sectors Reforms Projects With support from the World Bank

2002 Swajal Dhara Scaling up of the aboveVarious other initiatives such as

Bharat Nirman Yojana—for enhancing irrigation. Watershed projects given clear mandate to address drinking water supply programmes, especially in rural areas and several state supported programmes.

Specifi c focus on quality under Bharat Nirman Yojana

Multiplicity of schemes and agencies in operation

2002 National Water Policy Drinking water accorded the highest priority

2009 Framework for Implementation: 2009–2012∗

For ensuring people’s drinking water security in rural India

Source: GoI (2008). ∗ GoI (2009).


A plethora of studies have gone into examining the effectiveness of providing drinking water supply under different policy frameworks. These studies by and large highlight some of the inherent limitations of the policy initiatives, especially the sector reforms, by stressing that long term solutions to drinking water problems may be found only by reforming simultaneously the property rights regimes and resource prioritization, improving water resource management and promoting decentralised governance by promoting community participation. It is imperative to get out of the ‘sectoral approach’ where drinking water supply continues to be seen as part of the basic amenities/health services rather than being an important component of water resources management. The continued lapses and failure to meet the targets for providing safe drinking water to all is a manifestation of the ‘sectoral mindset’ governing water resources management in the country. Supply-driven approaches, notwithstanding the sector reforms,continue to remain the root cause of the problems.

The recent thinking on Integrated Water Resources Management (IWRM) holds potential for moving towards a comprehensive frame-work where drinking water supply assumes the highest priority in water resource management, rather than merely being treated as part of the social sector development and/or provisioning of basic infra-structure (Shah and Prakash 2008). The sector which has accorded the highest priority to drinking water ironically does not set the goals and targets for provision of water and sanitation facilities. There are limits to which centralised planning could help ensure water security for all; people-centric and bottoms-up approach thus forms a critical pre-condition for moving towards IWRM. Unless this is ensured, the issues of security, equity and resource sustainability as well as the issue of quality of drinking water would not be fully addressed. Attaining a convergence across different sectors as well as schemes thus poses the most critical challenges for attaining the goal of ‘water for all’ by the end of the 11th Five Year Plan, that is by 2012.

An important gap in the proposed shift towards a more holistic approach for water resource management is lack of adequate database for mapping, as well as monitoring the actual scenarios of access and quality of water across a large number of habitations (Das 2001).


This is important in the light of the fact that the once fully covered habitations are often likely to slip into the status of fully or partially covered. Apart from the institutional/administrative problems per-taining to repair and maintenance of the infrastructure, the real prob-lem arises from the fact that a large number of sources get dried upoften due to competitive withdrawals of groundwater for irrigation.The same phenomenon may hold good with respect to revived em-phasis on small water harvesting structures under watershed develop-ment or other schemes. While there is a lot of merit in reviving the traditional water harvesting systems, especially to enhance access to drinking water at village level, these initiatives need to be planned in a systematic manner taking appropriate hydrological units for planning and management. A comprehensive approach to resource planning and management assumes critical importance here.

Another important issue pertains to user contribution. Pricing needs proper assessment and institutional support for ensuring equitable and effi cient distribution of water across all households within rural habitations. The issues of equity, quality and sustainability are equally important for urban areas as a substantial proportion of urban water supply comes from privately augmented groundwater. Finally, it is essential to link water access with sanitation and the behavioural aspects attached to it. While bulk of water related diseases like malaria and diarrhoea need community level interventions for managing waterlogging and contamination, much needs to be done at the household level so as to ensure an effective cover against water-related healthhazards. The most critical element in the household/individual initi-atives is generating awareness and demanding water as a means to achieve the constitutional provision of ‘right to life’.

CONCLUSIONS

Exploring the interface between the three components—poverty, health and safe drinking water—the analysis reinstates the fact that poverty is both a cause as well as the result of ill-health, where a sig-nifi cant proportion of the burden of diseases is caused by limited access to safe drinking water. Whereas South Asia suffers from a high


prevalence of water-related diseases such as malaria, diarrhoea and anaemia, India with her vast and growing population accounts for a major share in water-related diseases in the region.

Twenty-eight per cent of India’s population consists of the poor. A large proportion of it seem to be trapped in a vicious cycle of poverty and lack of basic amenities including drinking water and sanitation. With growing privatisation of health services, this has resulted in higher expenditure on health which has eventually led to further loss of income and impoverishment. Undernourishment among children and adults has emerged as the most critical crisis facing human well-being. Widespread undernourishment has signifi cant negative impact on productivity and overall growth accounting for about 3 to 9 per cent of the country’s Gross Domestic Product (GDP). This is refl ected by the fact that sudden health shock is by far the most important crisis faced by a large number of rural households. With receding public sector amenities, the health shocks have exerted direct impact on household expenditure and indebtedness, especially among the poor.

According to NSSO estimates nearly 10 per cent of the country’s population reported morbidity during 2004–05, and one-tenth of these were due to water-related diseases. Although water-related diseases account for a fairly smaller proportion of the reported morbidity, the estimates indicated that the incidence of water-related diseases is higher among those in lower income/expenditure quintile whereas other morbidities, especially related to lifestyle, are found to be concen-trated among higher income/expenditure quintiles. Moreover, lower income/expenditure quintiles also have higher morbidity, especially among children, due to water-related diseases. Nevertheless, the crucial issues pertaining to equity, resource sustainability and institutional support are not getting adequately addressed. There is an urgent need for evolving a comprehensive framework for provisioning of drinking water as an integral part of water resource management with central thrust on community-based initiatives as pre-condition for attaining the multiple goals of effi ciency, equity and sustainability. This in fact may form a major agenda for moving towards an integrated approach for water resource management in the future.


REFERENCES

Abayawardana, S. and I. Hussain. 2002. ‘Water, Health and Poverty Linkages: A Case Study from Sri Lanka’ presented at Asian Development Bank Regional Con-sultation Workshop on Water and Poverty, Dhaka, 22–26 September. Available online at http://www.adb.org/water/actions/SRI/SRI_water_health_poverty.pdf. Downloaded on 21 October 2008.

Bell, E. and R. Goonesekere. 2000. Sri Lanka: Recapturing Missed Opportunities. Poverty Reduction and Economic Management – South Asia Region, Report No. 20430-CE, June, World Bank.

Bloom D., D. Canning, and J. Sevilla. 2001. ‘The Effect of Health on Economic Growth’, NBER Working Paper No. 5148, June.

Brudtland, G.H. 2001. Foreword, WHO World Water Day Report. Geneva: World Health Organization.

Das, K. 2001. ‘Rural Drinking Water Supply in India: Issues and Strategies’, inS. Morris (ed.), India Infrastructure Report 2001: Issues in Regulations and Market Structure. New Delhi: Oxford University Press.

Dev, S.M., K. Subbarao, S. Galab, and C. Ravi. 2007. ‘Safety Net Programmes: Outreach and Effectiveness’, Economic and Political Weekly, 42(35): 3555–65.

Dev, S.M. and C. Ravi. 2007. ‘Poverty and Inequality: All-India and States, 1983–2005’, Economic and Political Weekly, 42(3): 509–23.

GoI, 2009. ‘Movement towards Ensuring People’s Drinking Water Security in Rural India: Framework for Implementation 2009–2012’. Department of Drinking Water Supply, Ministry of Rural Development, Government of India,New Delhi.

Himansu. 2008. ‘What Are These New Poverty Estimates and What Do They Imply?’, Economic and Political Weekly, 43(43): 38–43.

Hirway I., S. Lodhia. 2007. Unpublished. ‘Status of Drinking Water in Coastal Regions in India: A Case for Area Specifi c Approach’. Ahmedabad: Centre for Development Alternatives.

MUHHDC (Mahbub ul Haq Human Development Centre). 2006. Human Develop-ment in South Asia 2006 – Poverty in South Asia: Challenges and Responses. USA: Oxford University Press.

Mallik, G. 2006. ‘An Examination of the Relationship Between Health and Economic Growth’, Indian Council for Research on International Economic Relations, Working Paper No. 185. September.

GoI. 2005. Report of the National Commission on Macroeconomics and Health, Ministry of Health and Family Welfare, Government of India, New Delhi.

NSSO. 2006. Morbidity, Health Care and the Conditions of the Aged in 2004”.60th Round, National Sample Survey Organisation, Government of India, New Delhi.

Patnaik, U. 2007. ‘Neoliberalism and Rural Poverty in India’, Economic and Political Weekly, 42(30): 3132–50.


GoI. 2002. ‘Water Supply and Sanitation’, A WHO–UNICEF Sponsored Study, Planning Commission, Government of India, New Delhi.

GoI. 2008. ‘Drinking Water, Sanitation and Clean Living Conditions’, Chapter 5, Eleventh Five Year Plan: 2007–2012, Planning Commission, Government of India, New Delhi.

Radhakrishna, R. 2005. ‘Food and Nutrition Security of the Poor’, Economic and Political Weekly, 40(18).

Ravallion, M. 2008. ‘A Global Perspective on Poverty in India’, Economic and Pol-itical Weekly, 43(43): 31–37.

Ravallion, M., S. Chen, and P. Sangruala. 2008. ‘Dollar A Day Revisited’, Policy Research Working Paper 4620, World Bank, Washington, D.C.

Seckler, D. 1982. ‘Small but Healthy: A Basic Hypothesis in the Theory, Measure-ment and Policy of Malnutrition’, in P.V. Sukhatme (ed.), Newer Concepts in Nutrition and Their Implications for Policy, pp. 11–64. Pune: Maharashtra Association for the Cultivation of Science.

Shah, A. 2008. Forthcoming. ‘Natural Resources and Chronic Poverty in India:A Review of Issues and Evidence’, CPRC–IIPA Working Paper, Indian Institute of Public Administration, New Delhi.

Shah, A. and A. Prakash. 2008. Unpublished. ‘IWRM in India: From Critique to Constructive Engagement’, Ahmedabad: Gujarat Institute of Development Research.

UNICEF. 2007. ‘Global Distribution of Under Five Deaths by Cause’. Available online at www.unicef.org/media/fi les/Under_fi ve_deaths_by_cause_2006_estimates3.doc. Downloaded on 20 October 2008.

UNDP. 2006. Human Development Report 2006 – Beyond Scarcity: Power, Poverty and the Global Water Crisis. United Nations Development Programme. Available online at http://hdr.undp.org/hdr2006/. Downloaded on 11 October 2008.

WHO. 2000. ‘Water Related Diseases’. World Health Organization. Available online at http://www.who.int/water_sanitation_health/diseases/diseasefact/en/index.html. Downloaded in June 2011.

PART II WATER SUPPLY, SANITATION

AND HUMAN HEALTH

72 Biraj Swain

4

Madhya Pradesh’s Complex Challenges

Undernutrition and Infectious Diseases

BIRAJ SWAIN

INTRODUCTION

INDIA IS HOME to 40 per cent of the world’s malnourished children and 35 per cent of the developing world’s low birthweight infants. Every year 2.5 million children die in India, accounting for one in fi ve deaths in the world (World Bank 2006). More than half of these deaths could be prevented if children were better nourished. India’s progress in reducing child malnutrition has been slow. While India witnessed a growth rate of 8–9 per cent in its Gross Domestic Product (GDP) from 1995–2005, the malnutrition reduction in the same period has been less than 2 per cent. Bangladesh, with a growth rate of 5.3 per cent during the same period, witnessed a malnutrition reduction rate of 3.5 per cent (World Bank 2006).

There has been a marginal reduction in child malnutrition at the national level from 47 per cent to 46 per cent1 (IIPS 1998–99, IIPS 2005–06). Infant mortality has declined from 68 per 1,000 births to 57 per 1,000 births during the same period. Also, during the time of NFHS-2 and NFHS-3, undernutrition rates in the central Indian state of Madhya Pradesh worsened considerably. The percentage of underweight children has considerably increased from 54 per cent to 60 per cent (NFHS-2 to NFHS-3). But there has been a decline in infant mortality from 88 per 1,000 births to 70 per 1,000 births.

1 National Family Health Survey: Multi-organisational survey on status of key health, family welfare and health indicators conducted every fi ve years in over 100 countries of the world. The fi ndings of the survey is used for planning and programme designing and research in demographics and health.

74 Biraj Swain

However, this decline in infant mortality and the credibility of the achievement was the focus of mainstream discourse again when the state experienced a spate of malnutrition deaths in 2008 in the districts of Khandwa and Satna. Between the three blocks2 of Khalwa (Khandwa), Unchehera (Satna) and Majhgawan (Satna), there were about 105 child deaths, although national dailies like the Times of India and the Hindustan Times quoted 165 child deaths.

This chapter examines the non-clinical reasons for this crisis. It traces the functioning of health and nutrition departments within the rubric of health and nutrition discourse on key determinants, the status of social protection programmes and the culture of public policy formulation without people’s participation. It explores how a combination of all these factors eventually led to the malnutrition crisis. It also examines Madhya Pradesh government’s responses, especially the concrete actions towards convergence that the state has been planning or has undertaken. The chapter urges for convergent action centred on health and nutrition and focusing on access to water and sanitation.

EXPLORING SOME HEALTH FACTORS Before linking deprivation of water and sanitation to the malnutri-tion burden, it is important to understand the status of some of the other key determinants in the state such as prevailing levels of hunger, physical access, education, awareness of feeding practices and water and sanitation, and so on.

The Hunger Dimension

According to the first-ever India State Hunger Index3 (ISHI), Madhya Pradesh has the most severe level of hunger in the country,

2 Lowest unit of administration in India, where developmental programmes are designed and funds disbursed.

3 Released by the International Food Policy Research Institute (IFPRI) in conjunction with Welthungerhilfe (formerly known as German Agro-Action) and the University of California, Riverside, the India State Hunger Index—2008, analysed hunger levels in 17 major states across India.

Madhya Pradesh’s Complex Challenges 75

followed by Jharkhand and Bihar. ISHI measures hunger on three lead-ing indicators and combines them into one index. The three indicators are prevalence of child malnutrition, rates of child mortality and the proportion of calorie-defi cient people. Scores of state hunger indices range from ‘serious’ to ‘extremely alarming’. India’s poor performance is driven by its high levels of child undernutrition and calorie insuf-fi ciency. Its rates of child malnutrition are higher than most countries in sub-Saharan Africa. Madhya Pradesh’s position in the index is at the bottom, at 30.90, and falls in the ‘extremely alarming’ category, lying between Chad (at 29.93) and Ethiopia (at 30.97). Notwithstanding that, Chad and Ethiopia are sites of chronic confl ict.

With its high levels of hunger, the vulnerable communities in under-served districts in Madhya Pradesh face the grave challenge of acquiring basic calories to sustain their health and well-being. A majority of tribal communities in the state continue to be vulnerable suffering from land alienation, indebtedness and deprivation of forest rights, which is further compounded by low literacy and high school drop-out rates and extreme poverty.

Barriers to Health and Well-being

Madhya Pradesh is the second largest state in India. Yet its road infrastructure is one of the least developed in the country. The road penetration of the state is 52 km per 100 sq. km compared to the country average of 75 km per 100 sq. km.4 In such a vast state, healthcare facilities are totally inadequate. Sub-health centres cover an average of six villages and a catchment area of 36 sq. km in Madhya Pradesh compared to the Indian average of four villages and 23 sq. km. Hence, while 100 villages get served by 25 sub-health centres on an average in India, in Madhya Pradesh the fi gures are 16–17 sub-health centres.

There is enough evidence that education of the mother and her awareness of caring and feeding practices are crucial to child survival (World Bank 2006: 68). The inability to access and assimilate qual-ity food at the household level, combined with lack of awareness of ante-natal, intra-natal and post-natal services increases vulnerability of

4 Madhya Pradesh Human Development Report 2007

76 Biraj Swain

both mother and child to repeated infections and diseases leading to undernutrition. At 14.9 per cent (NFHS-3), Madhya Pradesh has the lowest breast-feeding initiation5 rates in India. The picture continues to be bleak even after the child grows older. The exclusive breast-feeding rates are 21.6 per cent (again lowest in India) for children between 0–5 months’ age. Awareness amongst pregnant and lactating mothers is the key to changing the behaviour patterns.

‘The British Medical Journal has rated the provisioning of “clean water and sewage disposal” as the greatest advancement in medicine in the last 150 years, outscoring antibiotics, vaccines, anaesthesia and the discovery of the structure of DNA’ (GHW 2008).

States with the highest incidence of malnutrition score low in terms of access of households to toilets and civic amenities like drinking water (GoI 2008–09). But the relationship between water sanita-tion access and malnutrition and infant mortality is not unilateral. Madhya Pradesh has demonstrated that the lack of clean drinking water accelerates rate of child deaths as children are already suf-fering from a weak immune system because of acute malnutrition. Opportunistic infections are most liable when the body has already been broken down by acute protein energy malnutrition. The World Health Organization (WHO) asserts that 80 per cent of diseases are ‘water-related’, but what they actually imply is that the diseases are ‘sanitation-related’ (Black and Talbott 2005: 20). Bracketing these two areas with a WatSan approach to the public health agenda would provide an impetus to increasing investments in both water and sanitation programming.

Why Sanitation?

The WHO released a long list of water-associated communicable diseases affl icting people in poor environments, that is common eye and skin infections such as Trachoma and Scabies, and diseases such as malaria or yellow fever spread by mosquitoes living in swampy places. These were classifi ed into water-borne (diahorrea); water-washed (transportation of the parasite from one person’s bloodstream

5 Percentage of children breast-fed within an hour of their delivery. This is a key factor of building immunity amongst children.


to another’s); and water-based (intestinal worms, bilharzias and guinea worm). These water-associated diseases are responsible for 80 per cent of the world’s toll of sickness.

However, although water plays a role in transmission of diseases by providing the micro-organisms or parasites which carry the actual illness, it is unsafe sanitation practices and lack of environmental hygiene that lead to spread of infections. Infectious material gets picked up from the landscape or from other parts of the body, and enters the mouth via polluted fi ngers (Black and Talbott 2005: 94). It would be more accurate to describe the ‘water-related’ diseases as ‘sanitation-related’ and place more emphasis on causality, that is ‘reducing contact with disease-carrying agents wherever they are’.

The lack of waste management in India represents a major catastrophe for human well-being. Pathogenic material discarded in the open pose constant health hazard, especially to children. Water may be safe when collected from the source (hand pump, tap) but unless its safety is carefully protected en route to the household in the water pot, it becomes bacteriologically contaminated. The result is a vicious cycle of contaminated water leading to infectious diseases.

Water, Sanitation and Matters of Life and Health

Madhya Pradesh, with nearly 6 per cent of the country’s population, stands at the 25th position in literacy. The state has a high compos-ition of tribal population at 22.27 per cent (GoI 2001). Madhya Pradesh has 37.4 per cent of the population below the poverty line, 10 per cent more than the Indian average of 26.1. The sex ratio is 919 females per 1,000 males compared to the national fi gure of 933 females per 1,000 males. While the literacy rate at 63.7 per cent does not compare very badly to the Indian average of 64.8 per cent, the female literacy rate at 50 per cent is about 4 per cent less than the national average (GoI 2001).

In Madhya Pradesh, testing for water quality is the domain of Public Health Engineering Department (PHED). The community or the local self-governance institutions are not involved in the testing of water or in examining the test reports. The processes and procedures for water testing are based on random sampling methods and on com-plaints expressed. As such, there is no regular monitoring system for

78 Biraj Swain

testing quality of water, with the result that all water sources are not tested at regular intervals nor is a profi le of water quality developed for the villages/panchayats (WaterAid India 2006a).

It is worth mentioning that availability of quality water and sani-tation facilities do not ensure disease-free environment. The Asian Development Bank (ADB), under the Karnataka Urban Development Coastal Ecology Management Project, installed 100 per cent sanitation facilities in the Western Karnataka district of Karwar. However, the usage of the toilets was a low 55 per cent, with 45 per cent resort-ing to open defecation. In a similar ADB supported programme in Jodhpur, Rajasthan, 56 per cent people continued to resort to open defecation in spite of 100 per cent toilet construction support (Water-Aid India 2006a). Thus, issues of sanitation should be linked to and addressed along with planning for water. The approach to sanitation at the village level has been activity focused. The sub-components of sanitation—toilet construction, personal hygiene, solid waste disposal and liquid waste disposal—have been always addressed in isolation.

Further, there is lack of critical data at the state level for demand and supply of water. Madhya Pradesh has State Water Policy–2003 and draft Health Policy–2003. The former recognises the impor-tance of drinking water, but falls short of addressing the concerns of the poor, women and the issues related to sustainability. In the health policy, there has been no mention of water and sanitation as the key determinants of health. This is an important omission, as the policy downplays the ability of the communities to address the determinants and control their lives better. If the average statistics of Madhya Pradesh is disconcerting (data inadequacy notwithstanding), then the disaggregated story of the districts of Khandwa and Satna is more so.

KHANDWA AND SATNA: COUNTLESS CHALLENGES

Khandwa district is situated in southwest Madhya Pradesh. The dis-trict has 35.5 per cent tribal population and a sex ratio of 936 females per 1,000 males. The 12th round of 100 per cent weighing of children conducted by the Department of Women and Child Development (nodal department for supplementary nutrition programme) under the


Integrated Child Development Service (ICDS) project, reported that 55.45 per cent of the children were malnourished in various grades. Khandwa district is far from the capital city of Bhopal but well-connected by rail and road. In 2008, Khandwa received 33 per cent less rainfall. Many able-bodied tribal men in the villages went without any gainful employment.6 Food security is the fi rst casualty in such a scenario.

The Mahatma Gandhi National Rural Employment Guarantee Scheme (MGNREGS),7 a landmark scheme started in 2005, has not adequately addressed the distress of the local people (GoI, MGNREGS). The NREGA website suggests that Madhya Pradesh is far behind Andhra Pradesh, the state where NREGA was launched and where the scheme has been successfully implemented to a great extent. While Andhra Pradesh has been able to generate 67 days of wage work for every seeking family, Madhya Pradesh is at 46.5 days per 100 mandated days. The dysfunctional Public Distribution System (PDS)8 has further added to the food insecurity and hunger.

Khalwa: Ground Zero of Malnutrition Deaths

Khalwa is a block in Khandwa district. The highest vulnerability to infection and hence malnutrition exists during monsoon and pre-monsoon months. During June to early September 2008, 55 children reportedly died in this block with a population of 168,000, out of which over 67 per cent are tribals like Korpus, Shikaris and Yadavs. During the same period, more than 100 children suffering from acute malnutrition were admitted to the Nutrition Rehabilitation Centre9 (NRC) in the block. The causes of deaths as per the medical reports are given in Table 4.1.

6 During her fi eld visits between 3 and 5 November 2008, the author witnessed able-bodied men sitting idle with no wage-work. The same has been corroborated by the Government of India’s fact fi nding mission investigating into the spate of child deaths too.

7 National social protection programme for poor families guaranteeing 100 days’ of wage employment per household.

8 Social protection programme providing subsidised food to families living below poverty line.

9 Children suffering from severe and acute malnutrition are clinically rehabilitated here.

80 Biraj Swain

After respiratory disorders and fever, water-borne diseases were the highest cause of deaths. Other reported killers were measles, oedema, jaundice, sudden death, chickenpox and maternal death of newborns. Eighty-four per cent deaths occurred during August–September 2008. These are the months when the diarrhoeal diseases and viral infections are common and precipitate severe and acute malnutrition.

Eighty per cent of the 55 child deaths reported were registered at Anganwadi centres10 and were receiving supplementary nutrition. Twenty per cent of them had not been registered as ICDS benefi -ciaries, despite the Supreme Court injunction to Madhya Pradesh to universalise the scheme, that is to reach out to every eligible child and expecting mother by December 2008.

Statistics of key health determinants (water, sanitation and Anganwadi Centres) as per the Department of Public Health and Family Welfare survey as on December 2007 are given in Table 4.2.

As Table 4.2 clearly shows, the survey carried out by the health department enumerates the poor status of sanitation in the block. Interestingly, potable water access is better than sanitation facilities. Considering the fact that PHED looks after drinking water provision-ing while the Rural Development Department takes care of sanita-tion facilities, the table points at differential performance by two key

10 It is a community centre fi nanced through public funds for women and child development where a package of services are provided, that is supplementary nutrition for children of 0–6 years, pregnant and lactating mothers, early child edu-cation for children of 3–6 years and health and life-skills education for adolescent girls. It is the country’s most important response to the malnutrition challenge and child development goals.

Table 4.1: Malnutrition Deaths and their Medical Causes

Sl. No. Causes Number

1 Pneumonia/Acute Respiratory Infection 162 Diarrhoea 123 Fever 134 Stomatitis 45 Others 10

Total 55

Source: GoI (2008a).


Box 4.1: How the System Fails to Deliver

The author visited Namapur, Rajpura and Mirikheda villages in Khalwa block two months after the deaths, between 3 and 5 November 2008. Some of the observations from the visit are:

• The Anganwadi Centres (AWCs) were open for six hours, from 9.00 am to 3.00 pm and served three meals under the supplementary nutrition programme (SNP). The children and their mothers took the meals home instead of eating it at the centre.

• The Anganwadi workers (AWWs) often came from other villages, although it is mandated that she be a local resident. However, the sahayikas (helpers) were locals in the three villages.

• The villages had access to functional handpumps and potable water, though awareness about handling water—proper method of collec-tion, safe transportation and keeping in vessels—was either lacking or inadequate.

• Although the Mobile Health Clinic existed in Khalwa under the Deen Dayal Mobile Health Clinic Scheme, the AWWs (except in Rajpura) were unaware of its existence and the range of services it provided. Clearly, the government needs to popularise the entitlements of the Scheme to the villagers.

determinant departments of the Madhya Pradesh government. The block displays more than 25 per cent of partially covered habitations per safe drinking water requirement. Almost 25 per cent of the habi-tations face the challenge of inadequate access to safe drinking water. The block also displays a high number of AWC schools and villages having low or no access to toilet facilities. The ventilation and light-ing in most of the AWCs (for example, Mojwadi, Namapur) is very poor. Since children are supposed to spend most of their time in these centres, there are standard norms and designs for them which need to be child friendly. But ill-designed or inappropriately lit and ventilated centres are a deterrent for children to attend and also, these centres do not contribute to the health of the children present. The kitchens are very poorly constructed, lack ventilation and the food prepared in the wooden hearth results in lot of smoke. Under such circumstances, the prevalence of 58 per cent malnutrition in the area, that is 16,639 out of 28,834 children, as per the 2007 survey of the Department of Health, is not surprising.

82 Biraj Swain

Tab

le 4

.2:

Wat

er a

nd S

anit

atio

n St

atus

of K

halw

a B

lock

, Kha

ndw

a D

istr

ict

Num

ber o

f

Hab

itatio

nsFu

lly c

over

ed h

abita

tion

per p

otab

le w

ater

faci

lity

per 4

0 lit

res p

er c

apita

per

da

y (L

PCD

) nor

ms)

Part

ially

co

vere

d ha

bita

tion

per 4

0 LP

CD

no

rms

Unc

over

ed

habi

tatio

n pe

r 40

LPC

D n

orm

Rur

al

fam

ilies

w

ithou

t to

ilets

AW

Cs

with

out

toile

ts

Scho

ols w

ithou

t to

ilets

Vill

ages

with

out

acce

ss to

sani

tary

m

arts

198

162

36–

1415

226

219

7–

Sour

ce:

GoM

P (2

008–

9a).


Satna: Trapped in Agrarian Crisis

Satna district is situated in mid-northern part of Rewa Divi-sion in Madhya Pradesh. The Bundelkhand region, spread across Uttar Pradesh and Madhya Pradesh, of which Satna is a part, often undergoes cycles of acute agrarian crisis. The failed monsoons result in drinking water inaccessibility and agricultural water stress. The region has witnessed seven consecutive years of monsoon failure.11

About 14.34 per cent of the population is tribal and the sched-uled caste population is 16.27 per cent as per Census 2001. The malnutrition percentage for the district is 51.02 per cent as per the 12th round of Bal Sanjivani12 campaign conducted by the Integrated Child Development Service of the Department of Women and Child Development.

With only 14.23 per cent of Scheduled Tribe population, the district is not tribal dominated. But among the blocks, majority of tribal populations are in Maihar, Ramnagar and Unchehera blocks. All these have more than 20 per cent tribal population. Among these three blocks, Unchehera is different; it is second to Majhgawan in low population density with lot of hills and undulating plains.

Majhgawan and Unchehera have about 50 per cent and 45 per cent respectively of their total land under forest cover.

The health department reported 60 child deaths from these two blocks during June to September 2008. The causes of deaths are listed below (Table 4.3).

The leading United Nations agency for the Water Decade (1981–90), WHO, set out a large menu of water-associated communicable diseases affl icting people in poor environments. These were clas-sifi ed into water-borne such as Diarrhoea, water-washed such as Trachoma and Scabies, water-related such as Malaria or Yellow Fever spread by mosquitoes in swampy and water-logged areas and water-based such as intestinal worms, schistosomiasis, guinea worm.

11 GoMP12 Hundred per cent weighing of children was initiated by the Department of

Women and Child Development (DWCD) in 2006 to map and create a data base of absolute number of under-weight children by covering all the children of the state. This is done in a campaign mode, once every six months.

84 Biraj Swain

Tab

le 4

.3:

Cau

ses

of C

hild

Dea

ths

in S

atna

Bloc

ksPo

ssibl

e Cau

ses o

f Dea

ths

Num

ber o

f Rep

orte

d D

eath

s as

Per t

he H

ealth

Dep

artm

ent

Soci

al C

aste

/Pro

fi le o

f the

D

ecea

sed

Chi

ldre

nEn

rolm

ent S

tatu

s of t

he

Chi

ldre

n

Maj

hgaw

anV

iral f

ever

/Enc

epha

litis/

brai

n fe

ver (

12)

Sept

icem

ia (6

)A

cute

Res

pira

tory

Infe

ctio

n (A

RI)

(6)

Dia

rrhe

oa/v

omiti

ng (2

)T

win

s Low

Birt

h W

eigh

t/St

illbi

rth

(2)

Hep

atiti

s (1)

Oth

ers (

15)

46Sc

hedu

led

Cas

te (1

)Sc

hedu

led

Trib

e (M

avas

i, G

ond

and

Kol

) (42

)O

ther

Bac

kwar

d C

aste

s (3)

Enro

lled

in A

ngan

wad

i C

entr

es (2

1)N

ot e

nrol

led

due

to n

on-

avai

labi

lity

of A

WC

(14)

Scho

ol g

oing

chi

ldre

n (1

1)

Unc

hehe

raH

eat S

trok

e (5

)V

iral f

ever

(4)

Sept

icem

ia (1

)A

cute

R

espi

rato

ry In

fect

ion

(2)

Hep

atiti

s (1)

Unk

now

n (1

)

14Sc

hedu

led

Trib

e (K

ol) (

14)

Enro

lled

at A

WC

(4)

Not

enr

olle

d (7

)N

ewbo

rn (P

regn

ant

mot

her w

as e

nrol

led)

(1)

Not

enr

olle

d du

e to

non

-av

aila

bilit

y of

AW

C (2

)

Sour

ce:

GoI

(200

8b).


(Black and Talbott 2006: 94) These water-associated diseases are blamed for 80 per cent of the world’s toll of sickness.

Though water plays an important role in transmission by providing the micro-organisms which carry the actual illness with a habitat and transport system, ‘unsafe sanitation’ practices and lack of environ-mental hygiene, rather than water itself, are at the root of the spread of these infections.

In small bodies weakened by poor nutrition, the effect of unsafe or questionably safe drinking water and poor sanitation can be devastat-ing. This is the primary cause of deaths amongst India’s under-fi ves (Black and Talbott 2006: 97).

ICDS is being implemented in both Unchehera and Majhgawan. There are 152 and 250 Anganwadi Centres in Unchehera and Majhgawan blocks respectively. Both are 45–50 km away from the district headquarters. Needless to say, the Khandwa (Khalwa) story repeats itself. Both the blocks are fairly distant from the district head-quarters in remote inaccessible location.

Statistics of key health determinants—water, sanitation and Anganwadi centres—as per the survey of the Department of Public Health and Family Welfare as of December 2007 in the two blocks are given in Table 4.4.

Table 4.4 clearly illustrates the Department’s lack of understanding of the importance of determinants on health—it has zero numbers on the survey sheet for sanitation. A zero narrative, combined with inadequate data, makes service programming and delivery a challenge. While it is a cause, it is also an effect of low priority of sanitation and AWCs in the district.

In September 2008, the Satna Fact Finding Mission visited Chandikuan village and reported lack of adequate system for drain-age of waste water from the village and people being forced to live in unhygienic conditions. Many children complained of skin diseases, anaemia and worm infestations. Although no child death was reported in the village, the villagers were not getting benefi ts of rural develop-mental programmes—proper sanitation, construction of road, clean-ing of wells and roads and electrifi cation and so on—through the local panchayat. Delay in taking children to the nearest primary health centre or hospital, either due to inadequate awareness of the severity of

86 Biraj Swain

Tab

le 4

.4:

Hea

lth

Det

erm

inan

t Sta

tus

of M

ajhg

awan

and

Unc

hehe

ra B

lock

s, S

atna

Dis

tric

t

Nam

e of t

he

Bloc

kN

umbe

r of

Hab

itatio

ns

Num

ber o

f H

abita

tions

Ful

ly

Cov

ered

per

40

LPC

D N

orm

Num

ber o

f Hab

itatio

ns

Part

ially

Cov

ered

per

40

LPC

D N

orm

Num

ber o

f H

abita

tions

not

C

over

ed

Num

ber o

f Fa

mili

es

with

out

Toi

lets

Num

ber o

f AW

Cs

with

out

Toi

lets

Num

ber

of S

choo

ls w

ithou

t T

oilet

s

Num

ber

of V

illag

es

w-w

ithou

t Sa

nita

ry M

arts

Maj

hgaw

an79

459

019

707

––

––

Unc

hehe

ra44

428

912

926

––

––

Sour

ce:

GoM

P (2

008–

2009

b).


the problem on the part of their parents, or their inability to transport the sick children to the hospital in time, was a major cause of death.

Caste played a critical role, as villagers from the lower castes com-plained that the sarpanch, panchyat head, who belonged to the higher caste (Thakurs), siphoned off funds meant for rural development. It is important to mention that these families had not been given any medicines and/or counseling by AWW, the frontline delivery staff of the ICDS, and/or the Auxiliary Nurse Midwife (ANM), the frontline delivery staff of the health system. The inability of the system to reach the end-user, remains the single most important challenge abetting the malnutrition crisis.

Livelihoods, Water Sanitation and the Larger Challenges

The high prevalence of illiteracy in the affl icted villages and the lack of awareness of basic health, hygiene and nutrition issues for the children and their mothers were realities. But the reality of food insecurity and livelihood insecurity could not be emphasised enough. The acute poverty and water-stress under the circumstances make the practice of some of these nutrition and hygiene messages non-starters. Women are forced to trudge long distances to collect fuel wood and water while the men-folk are constantly on the move in search of daily wage-work.

Most of the tribal children of the state, as high as 82.6 per cent in the age group of 6–35 months are anaemic (IIPS 2005–06). Besides acute poverty, worm infestation, thanks to water contamination, and malaria are the major reasons for their poor health status. People are forced to resort to springs and rivulets dispensing polluted water.

The Road Ahead: Tackling the Last First

Combating persistent undernutrition and endemic deprivation—as opposed to transient famines and crises—requires more than just public policy responses. The phenomenon of endemic deprivation is much more pervasive and affects many more times the number of people threatened by famines (Sen and Dreze 1991). Undernutrition cannot be divorced from the problem of morbidity and ill-health.

88 Biraj Swain

Basic education too has a major role in the eradication of both undernourishment and preventable morbidity. This is not just because education helps in the use of one’s personal means to buy food and medicine in a more informed way, but also because widespread elementary education leads to greater utilisation of public health services. Furthermore, it can also generate effective political demand that such services be effectively provided.

Undoubtedly, preventing diarrhoea and other sanitation and water-related diseases can have a huge impact on improving children’s lives.

In response, ICDS impact assessment has been undertaken by the state planning commission along with the Department of Women and Child Development DWCD to fi nd out the operational and other challenges in the implementation of the same. Mapping of water sanitation facilities, along with the physical penetration of AWC, is the core remit of this assessment. Child feeding practices and awareness levels of key health determinant issues, especially behavioural aspects of health, water-sanitation and nutrition, are some of the other major interventions being designed by the state in partnership with civil society actors and donors. A mega Behaviour Change Communica-tion (BCC) campaign is being planned by the state in those lines with special focus on remote areas and indigenous population.

Water stress, distance of the healthcare facility, absent or dysfunc-tional public distribution system, the sub-optimal AWC and the absent and/or stretched frontline delivery staff need to be reversed. Early childhood development and education need to be prioritised for the children of Khalwa, Majhgawan, Unchehera specifi cally, and the children of Madhya Pradesh generally, to give them a real chance for life.

Strengthening Governance: Prioritising Citizens’ Action

Citizens’ engagement requires the state’s commitment towards cap-acity building. However, the state’s investment in capacity building, both fi nancial and non-fi nancial, has been fairly low. The Village Health Sanitation Committees which are the grassroot structures for communitising health, sanitation and nutrition have not yet taken off in the manner and pace that would have made nutrition and health everyone’s agenda.


Low demand of employment guarantee programme, low participa-tion of citizens or non-state actors in monitoring it, and resistance of the State machinery to citizens’ participation in critical sectors like health, nutrition and livelihoods are all pointing to the missing citizens in Madhya Pradesh, the state which initiated the grassroots democracy. These sectors are technical and their administration is a maze but these sectors are vital too and those are precisely the reasons why they need to be everybody’s business.

Of Hunger, Unemployment and Undernutrition

The Madhya Pradesh experience establishes that nourishment appears to be also an outcome of non-food factors, that is medical attention, health services, basic education, sanitary arrangements, provision of clean water, eradication of infectious epidemics, and so on. The recognition of this does not, of course, imply that importance to the defi ciency of food intakes as such is any less. Eating is a major aspect of living, and the physical and psychological aspects of hunger—directly related to food intake—needs to command attention (Sen and Dreze 1991).

Lack of income-generating opportunities is a stark reality in the affected districts and blocks. Federal national government’s ‘injections’ of investments and multi-funded programmes notwithstanding, the public participation in these programmes has been low. Undoubtedly, children from vulnerable communities will be at lower risks if access to education, water, sanitation, healthcare and nutrition is consistent and strengthened.

CONCLUSION Nutrition and Sanitation, Both Low Priority

There is little demand for nutrition services from communities because malnutrition in terms of symptoms is frequently invisible and its lifelong implications often unrecognized. Families and commu-nities are unaware that even moderate and mild malnutrition contrib-utes substantially to death, disease, low intelligence and fi nally low productivity. Most communities have inadequate understanding of what contributes to malnourishment. Symptoms of malnourishment

90 Biraj Swain

do not reveal themselves easily to the untrained eyes and hence the silent killer continues to stalk.

The predominant focus on food and on nutrition treatment versus prevention is disproportionate to the role played by them to improving the overall nutritional status of children in India. Health and hygiene, immunisation, water and sanitation, infant feeding and caring practices and beliefs at household and community level are as critical to good nutrition, as are food inputs. Community members have limited capacity and power to exercise and realise their rights to water, sanitation, health and education and to ensure accountability of service providers. Low status of women and gender inequities under-mine the role women can play in enhancing nutrition levels. A large proportion of girls and women are severely anaemic well before their pregnancy, which compromises their ability to give birth to healthy babies. Intra-household food insecurity combined with failure in targeting ICDS supplements to mothers has resulted in low impact on better nutritional status of women and consequently children.

Discrimination faced by socio-economic and ethnic groups fur-ther erodes their ability to access entitlements that have a bearing on their nutrition. It is little wonder that the malnutrition fi gures are the worst in the lowest quintile of the population which faces mul-tiple marginalisation and Khandwa and Satna districts with Khalwa, Majhgwan and Unchehera blocks are manifestation of the same. Com-munity monitoring systems that are neither suffi ciently decentralised nor effective have failed to ensure that the programmes deliver per mandated entitlements. The understanding, role and commitment of local governance institutions in bringing the nutrition agenda to centre-stage and ensuring accountability have been unclear and weak. Public participation, in terms of understanding, monitoring or work-ing vigilantly for better programming is almost non-existent.

Child Survival and Funding Patterns

The pressure on child survival and the need to show tangible health outcomes has made infl uential multilateral agencies like United Nations Children’s Fund (UNICEF) and bilateral donors like the Department for International Development (DFID) scale down their interventions in water sanitation and focus on quick-fi x remedies


like mass immunization or oral rehydration therapy for diarrhoeal dehydration, which are principally medical intervention.

Hence investing in programming for water-sanitation requires a long term perspective. It is nobody’s case to either support water sanitation, or vaccines or immunisations and ORS. But to allocate all the resources into ORS and vaccines without investing in underlying issues of improving water sanitation access would only contribute to treating the symptoms. Hand pumps and toilets might be impor-tant for public health over the long term, but in terms of dramatic and demonstrable reductions in young child deaths, they could not compete with medical technology. More could be done faster and cheaper to save children’s lives by needles, rehydration solutions and basic medicines than by the preventive strategy of water points, toilets, hygiene and health education (Black and Talbot 2005).

Ensuring Convergence Actualises

There are multiple organisational stakeholders who need to main-stream issues of nutrition in their respective sectoral messages and programmes. But at the same time some of the manifestations of malnutrition, like micro-nutrient defi ciencies of iodine, iron and Vitamin A, cannot be tackled by the Department of Women and Child Development. In fact, this calls for complex institutional integration of the Departments of Women and Child Development; Public Health and Family Welfare; Education, Public Health and Engineering and Panchayati Raj.

The state’s response to malnutrition deaths has been a long hard look at the state of convergence between the key depart-ments. Grassroots convergence has been initiated by merging all the village level committees, which had been mandated separately with separate agenda such as health, water-sanitation and nutrition, into one single committee at the grassroots level. As the Economic Sur-vey of India, 2008–2009 aptly points (HT 2009) towards a ‘larger impact beyond nutrition to other health outcomes, a comprehensive programme to improve civic amenities of a public health nature is important if the divide between the rich and the poor is to be bridged. Access to public goods must be improved’ (GoI 2008–09).

92 Biraj Swain

The geographic challenges, that is distant location, inaccessibility, scattered habitations, gaps in Public Distribution System (PDS) and poor transportation are being addressed through a rigorous mapping of habitations and the spread of PDS. The road network is being widened to increase accessibility in the state. Other determinants like availability of safe drinking water, spread of sanitation facilities and ensuring usage, making referral transport available and budget-ing for the same in the decentralised planning are being prioritised in the state action through bottom-up Decentralised Health Action Plan (DHAP). The Mobile Health Clinic Scheme, that is Deen Dayal Mobile Health Clinic Scheme, is being overhauled to ensure it really reaches spaces and geographies that it is mandated to.

Periodic independent assessments of programmes in the most under-served locales and communities, re-vamping the monitoring systems and investing in quality data generation and usage cap-acity is increasingly gaining ground. Inter-departmental monitoring mechanisms have been initiated with health and health determinant departments taking the initiative. Weekly public hearings have been initiated by block13 level offi cials and even the district commissioner14 across all the departments to make offi cials and the line ministries more accessible. The fact that good health and nutrition are not just the function of the nodal departments but the responsibility of the state is increasingly gaining acceptance.

REFERENCES

Black, M. and R. Talbot. 2005. Water—A Matter of Life and Health. New Delhi: Oxford University Press.

GHW. 2009. People’s Health Movement: An Alternative Global Health Watch’, World Health Report 2, Global Health Watch, London: Zed Books.

GoI, Census 2001. Offi ce of the Registrar General and Census Commissioner, Ministry of Home Affairs, Government of India, New Delhi

GoI, Mahatma Gandhi National Rural Employment Guarantee Scheme, Ministry of Rural Development, Government of India. Available online at http://nrega.nic.in/. Downloaded on 30 December 2008.

13 Block is the lowest unit of administration and fund disbursal in India14 Commissioner is the designated executive head of each department at the sub-

national/state level.


GoI. 2008a. Report of the Fact Finding Mission on Malnutrition Related Deaths of Children, Khandwa District, Madhya Pradesh. Ministry of Women and Child Development, Government of India, September.

GoI. 2008b. Report of the Fact Finding Mission to Satna District, Madhya Pradesh, Ministry of Women and Child Development, Government of India, September.

GoI. 2009. Economic Survey of India, Ministry of Finance. Government of India. New Delhi: Oxford University Press.

GoMP. Water Resources Department, Government of Madhya Pradesh. Available online at http://www.mp.gov.in/wrd/. Downloaded on 18 August 2009.

GoMP. 2008–09a. Satna Integrated District Health Action Plan, National Rural Health Mission, Department of Public Health and Family Welfare, Govern-ment of Madhya Pradesh.

GoMP. 2008–09b. State Programme Implementation Plan, National Rural Health Mission, Department of Public Health and Family Welfare, Government of Madhya Pradesh.

GoMP. 2008–09c. Khandwa Integrated District Health Action Plan, National Rural Health Mission, Department of Public Health and Family Welfare, Govern-ment of Madhya Pradesh.

Haddad, L. and S. Zeitlyn (eds). 2009. Lifting the Curse: Overcoming Persistent Undernutrition in India. Institute of Development Studies, Sussex, Bulletin 40(4). July.

HT. 2009. ‘Amenities Link to Malnutrition’, Hindustant Times, HT Live, Bhopal, p. 3.

IIPS. 1998–99. National Family Health Survey-2, Mumbai: International Institute of Population Sciences.

———. 2005–06. National Family Health Survey-3, Mumbai: International Institute of Population Sciences.

———. 2007–8. District Level Household and Facility Survey-3. Mumbai: Inter-national Institute of Population Studies, District Level Household and Facility Survey–3,

Menon, P., A. Deolalikar and A. Bhaskar. 2008. The India State Hunger Index: Comparisons of Hunger across States. Delhi: International Food Policy Research Institute.

Sen, A. and J. Dreze. 1991. Hunger and Public Action. New Delhi: Oxford University Press.

WaterAid India. 2006a. Water for All? Implementation of ADB’s Water Policy in India: A Review. Delhi: WaterAid India.

World Bank. 2006. Repositioning Nutrition as Central to Development: A Strategy for Large-scale Action. Washington, D.C.: International Bank for Reconstruction and Development.

5

Inequalities in Access to Safe Drinking Water, Sanitation and Childhood

Undernutrition in India

WILLIAM JOE AND UDAYA SHANKAR MISHRA

INTRODUCTION

GLOBALLY MILLIONS OF individuals suffer from water–sanitation–hygiene (WSH) related illnesses each year. In fact, an estimated one-tenth of the global burden of disease can be attributed to WSH related issues.1 In developing countries, untoward WSH conditions cause a large number of deaths among children, especially in households belonging to lower socio-economic strata2 (WHO/UNICEF 2004). It must be acknowledged that in the absence of other facilitating attributes, WSH-related improvements alone would not ensure better health outcomes. For example, in the absence of safe water use behaviour, availability of safe drinking water alone may not necessarily ensure improved health outcomes. Consequently, an uneven distribution of these factors can lead to situations where health failures of some individuals or groups become more acute than those of others, thus engendering health inequalities.3

1 In recent times, the overall disease burden related to unsafe water, sanitation and hygiene was fi rst examined at a global level in 1990 (Murray and Lopez 1996). Thereafter, there have been several revisions to this estimate based on a systematic and transparent method (see, for instance, WHO 2002; Prüss-Üstün et al. 2004; Cairncross and Valdmanis, 2006).

2 The World Health Organization estimates that in developing countries, four million children (aged less than fi ve) die each year from diarrhoea. http://www.who.int/aboutwho/en/preventing/diarrhoeal.htm.

3 There exists a difference between health inequality and inequity. Health inequal-ity is an empirical concept, which gauges the difference in health outcomes between

Inequalities in Access to Safe Drinking Water 95

Given the severity of this problem, many governmental and non-governmental organisations (NGOs) have determined to enhance access to improved water and sanitation facilities, and also to bridge the rich–poor gap in health outcomes. But their intent cannot proceed very far without a prior assessment of the magnitude of the problem; and it is to this rather elementary question that this chapter is addressed.

This chapter draws its motivation partly from the need to gather insights from the Indian experience to further understand the WSH–health nexus, and partly to arouse policy attention to enhance health equity by improving access to safe water supply and sanitation. It may be emphasised that addressing the issues of access to safe water and sanitation not only widens the interpretation of poverty but also attaches greater relevance to the problem from the perspective of social justice and equity.

From a policy perspective, the results presented in the chapter provide the much-needed pointers for socio–political and develop-mental discourse, so that individuals and households are well equipped to escape the vicious combination of inadequate WSH and health deprivations. An improved understanding of the complex social reality helps in executing and prioritising more effi cient health interventions. This chapter contributes to the literature on water and sanitation by adopting an equity perspective. The scope of this chapter is restricted to the analysis of inequalities in access to water and sanitation and its role in determining childhood undernutrition, an indicator of population health.

Undernutrition is a major public health issue in South Asia. India, a major country in the region, both in terms of geographical area covered as well as size of its population, is no exception to this pattern—one out of every two Indian children endure some form of nutritional deprivation (IIPS and Macro International 2007). From a human rights perspective, it clearly hampers the development of basic capabilities and functioning and disregards the child’s right to lead a healthy life (Sen 1999). Given its relevance, both for policy and social

social groups defi ned by variables such as class, race, gender and geographical locations. Health equity includes concerns about achievement of health, capability to achieve health, fairness in the delivery of healthcare and is also integrated with broader issues of social justice and overall equity (Sen 2002).

96 William Joe and Udaya Shankar Mishra

justice, the pervasiveness of WSH-related health inequalities in India require a concerted engagement.

CHILDHOOD UNDERNUTRITION, WSH AND HEALTH INEQUALITY: AN ANALYTICAL FRAMEWORK

What are the implications of inadequate WSH on childhood under-nutrition? It is well documented that a precarious WSH condition significantly enhances the risk of infections and contributes to undernutrition (Checkley et al. 2004, Esrey 1996, Esrey et al. 1992). These studies have concluded that inadequate WSH leads to repeated diarrhoeal diseases and parasite infestations. These recurring gastro-intestinal infections may eventually lead to reduced absorption of nutrients, creating a negative impact on the nutritional status of an individual. However, it could be argued that children may be sick and underweight not only because of less access to safe water and sanitation but also because their parents are less knowledgeable about how to obtain the maximum health benefi ts from the available facilities (Jalan and Ravallion 2003; Wagstaff and Nguyen 2003). In other words, apart from WSH conditions, there are various other determinants that have a differing impact on nutritional health in terms of its magnitude and its direct or indirect Effects.

Therefore, the framework presented here particularly emphasises not only on the composite nature of the WSH-related factors but also on other direct and indirect determinants of children’s nutritional status. For example, unsafe water and hygienic practices at the house-hold or individual level can lead to infectious Diarrhoea (intestinal nematode infections, hookworm disease, and trachoma) and intensify undernutrition. Similarly, at a macro-level, poor water management and changes in water ecologies can lead to the proliferation of vectors of certain diseases such as malaria, dengue, schistosomiasis, lymphatic fi lariasis, and arbovirus infections (Fewtrell et al. 2007).

As shown in the framework, there are three exogenous pathways, namely physical–environmental features, household-related aspects and community specifi c-effects that directly or indirectly determine the nutritional health of children. Among the three pathways, physical–environmental factors pose a direct threat to child health. Individuals


exposed to environment-induced risks fall prey to diarrhoea and other infectious diseases. In the absence of adequate healthcare provisioning or lack of maternal education and awareness, such risks can leave a child vulnerable to undernutrition. In fact, epidemiological studies on global disease burden and the environment have estimated that 50 per cent of undernutrition problem is caused due to local envi-ronment, essentially because of an association between poor water quality and infectious Diarrhoea (Hunter et al. 2003, Prüss-Üstün and Corvalán 2006).

In developing countries, the issue is not just about water con-taminated at source or its distribution, but also how water is stored (Gundry et al. 2004). Clearly, it emphasises the relevance of water quality management and issues related to sanitation and hygiene.4

The household forms the second-most crucial link to comprehend differences in nutritional health of children. It can be observed that this pathway instigates health inequality in two different ways. First, differences in household income and educational levels lead to differ-ences in the levels of WSH across households. As a result, households with better income levels are expected to have improved access to safe drinking water and sanitation. Furthermore, if the household members are educated, then they are likely to have an improved hygiene level at home. From an analytical perspective, a defi nite impact of income and education on health and its interaction is of greater relevance. Households which are deprived in terms of income and education are undeniably at higher risks of infectious diseases and undernutrition. Second, awareness regarding safe water use practices could minimise risks even if households do not have access to improved sources of water or sanitation. There is also need to examine certain other import-ant aspects including child specifi c biological aspects (such as weight at birth), issues of immunisation and maternal health.

The third exogenous pathway of community specifi c effects is expected to instigate health inequalities through two broader routes. These effects assume the WSH route in communities who are deprived

4 On this issue, Ahmed et al. (1993) compares cleanliness and diarrhoea levels in villages with and without hygiene education interventions and observes that higher adoption rates of the intervention were associated with a better cleanliness state, which was paralleled by a decrease in diarrhoea and undernutrition rates.


of public provisioning—in terms of adequate supply of safe water and adequate sewerage systems. Often, geographical disadvantage escalates the costs involved in providing basic services such as safe water supply and sanitation facilities. Other than elementary fi nancial constraints, community deprivations can arise due to general neglect or margin-alisation of the community in the socio-political domain. But even if a community receives an undivided attention of the social planner, there are certain intra-community factors, which can adversely affect child health. Primarily, these factors are social norms and cultural elements. The most common case, in this context, is that of gender discrimination in diet and healthcare that continues to be a major disadvantage for female children. It is noticed that girl children are not only discriminated against in food and healthcare but also in

Figure 5.1: Framework of WSH, Child Undernutrition and Health Inequalities


terms of educational opportunities. Moreover, women’s status in the household also affects physical and psychological health of the mother and children. Often, additional labour for household activ-ities and lack of social and economic autonomy also force women to live with degenerated health status. Although efforts have been made to dismantle such blockades, it will take long time to actually change the prevailing social outlook.

In a given society, all these factors and instrumental mechanisms are found to vary within households or communities and health dif-ferences instigate health inequalities precisely because of this reason.

DATA AND METHODS

This study uses the 2005–06 National Family Health Survey-3 (NFHS-3) data whose structure and format for information collec-tion is similar to the Demographic and Health Surveys (DHS). The NFHSs, initiated in the early 1990s, have evolved as a nationally important source of data on population, health and nutrition for India and its states. This data provides information on nutritional status of children in terms of anthropometric measures along with informa-tion on household assets, accessibility to water and sanitation facilities as well as certain other aspects related to maternal and child health. For measuring nutritional status we resort to the standard physi-cal indices that describe nutritional status of children in terms of height-for-age (stunting), height-for-weight (wasting) and weight-for-age (underweight). Stunting refl ects long term effects of under-nutrition caused by failure to receive adequate nutrition over a long period of time. Wasting implies failure to receive adequate nutrition in the period immediately preceding the survey and may be the result of inadequate food intake or a recent episode of illness causing loss of weight and the onset of undernutrition. Underweight is a composite index of height-for-age and weight-for-height. It takes into account both acute and chronic undernutrition (IIPS and Macro International 2007).

In this study the measure of weight-for-age (underweight) is used to study undernutrition inequality and the impact of WSH and other


related factors on it (see appendix). It is well documented that inad-equate water and sanitation facilities and problem of undernutrition are strongly correlated with factors such as income poverty. There is a greater concentration of inadequate water and sanitary facilities among the poorer sections of the population. Similarly, the poor disproportionately share the burden of undernutrition.

However, the magnitude of concentration of such water, sanitation and health deprivations can considerably vary across states or regions. Therefore, in order to quantify and compare such income-related inequalities in health the widely used indicators of Concentration Curves (CC) and Concentration Index (CI) are used.

Statistically, in these measures ‘equality’ is defi ned as a condition when the deprivation in society is equally distributed across the differ-ent sections of the population. For example, consider a hypothetical society consisting of 10 individuals and fi ve water taps. Now, in Case A, if all the taps are owned by the fi ve rich individuals—ranked in terms of income or asset—then we can infer that the deprivation of water taps is entirely concentrated among the poorer individuals. In Case B, if two of the fi ve taps are owned by poor individuals and three by the richer ones, it indicates that the concentration of deprivation among poorer sections is relatively lower than in Case A. Accord-ingly, the statistical measure of CI will provide higher values to higher levels of deprivations. Thus, the CI value would be higher in Case A and relatively lower in Case B. The CI measure ranges between –1 and +1. If CI is negative then it implies that deprivation is concentrated among the poorer sections of the population.

Also, higher CI value implies greater inequality. The CC plots the cumulative proportion of the population—beginning with the most poor in terms of income or socioeconomic status and ending with the least poor—against the cumulative proportion of deprivations, say in health or water. If deprivations are equally distributed across socio-economic groups, CC will coincide with the diagonal. If depri-vation is concentrated among the lower socioeconomic groups, CC would lie above the diagonal. The further the diagonal, the greater the degree of inequality. Some technical details pertaining to this method are provided in the appendix.


ANALYSIS

Underweight or weight-for-age is a composite measure of height-for-age (or stunting captures chronic nutritional inadequacies or ill-ness) and weight-for-height (or wasting captures current nutritional status) and could be used for monitoring growth and to assess changes in the magnitude of undernutrition over time. Underweight outcomes are signifi cantly correlated with stunting and wasting. NFHS-3 (2005–06) data reveals that 48 per cent of the child population is stunted and 43 per cent is underweight. The prevalence of wasting is also quite a serious problem in India (20 per cent). The problem of severely stunted (24 per cent) and underweight (16 per cent) children is also substantial. With almost one out of every two children being undernourished at the national level, the regional dispersion of the problem cannot be expected to be any better. For instance, this prob-lem is much more concentrated among low-income states of Madhya Pradesh, Bihar, and Jharkhand. A few states such as Kerala, Punjab and smaller states such as Goa, Mizoram, Sikkim and Manipur experience relatively lower levels of undernutrition. Undernutrition outcomes are worse in rural areas than in urban areas, although by no means could the urban nutritional scenario be labelled as reasonable.

Children from households with a lower standard of living are twice as likely to be undernourished as children from households with a higher standard of living (IIPS and Macro International 2007). Although it is an obvious fi nding, nevertheless its non-triviality prompts us to analyse health inequalities that get manifested along the income domain. Furthermore, if we disaggregate the overall underweight outcomes based on sex of the child very little evidence of gender disparities is observed. By and large, this holds true even if the disaggregation is performed on the basis of wealth quintiles (Figure 5.2). Perhaps, this does not strongly support the hypothesis of intra-household bias at the all-India level, but inferences may vary if viewed from a regional perspective or along any other socio-economic dimension.

Data from NFHS-3 suggests that around 20–30 per cent of children less than six months of age—breastfeeding period—are found to be undernourished. This is indicative of poor maternal dietary intake


and supplementation both during pregnancy and after childbirth. The fi nding on mother’s education vis-à-vis child’s nutritional perfor-mance revalidates the strongly grounded negative relationship in the literature between the two. Mothers with no education have higher proportions of undernourished children compared to those who have been to at least high school. Here it could be argued that poor educa-tional status might be contributing to the undernutrition outcomes among the breastfed babies especially through the route of hygiene.

Further, in this research a strict defi nition of safe water and sani-tation has been applied to assess their distribution across the Indian states. Safe water is defi ned as water accessed from piped water supply (own or public tap), bottles or water consumed by households after purifying it. Water from all other sources and without any purifi cation is considered unsafe for consumption. Similarly, adequate sanitation strictly applies to only those households who have fl ush latrine/toilet facility connected to a proper sewer system, septic tank or pit latrine. Community toilets and shared toilets are not included in this strict

Figure 5.2: Prevalence Rate of Underweight by Wealth Quintiles, Disaggregated by Sex

Source: IIPS and Macro International (2007).


defi nition as they are not considered to contribute to improved sanita-tion facility (IIPS and Macro International 2007). Hence, households using facilities other than the specifi ed facilities are classifi ed as those with unsafe sanitation facilities. It must be noted that the all India fi gures presented in Tables 5.1 and 5.2 include all the states and union territories. Though similar analysis can be performed for all the states, for analytical convenience and partly due to space limitations the state-wise analysis presented here is restricted to 18 states only. These states have a larger sample size in the NFHS survey than the rest.

A region-wise scrutiny suggests a desolate picture of the distribution of water and sanitation facilities with a greater burden of deprivation observed among the economically backward states (Table 5.1).

In all of India, 44 and 73 per cent of surveyed households do not have access to adequate water and sanitation facilities respectively. These deprivations also show greater variations across the major states of India. In terms of inadequate water facilities, the deprivations range from a low of six per cent in Gujarat to 93 per cent in Bihar. Similarly, inadequate sanitation ranges from 12 per cent in Kerala to 89 per cent in Orissa. In case of sanitation, in all states except Kerala, depriva-tions among the surveyed households are more than 50 per cent. The south Indian states have relatively better access to safe water facilities in comparison to others. The NFHS-3 fi gures indicate that almost 43 per cent of the Indian children are underweight. With almost one out of every two children being undernourished at the national level, the regional dispersion of the problem is not any better. However, this problem is more concentrated among low-income states of Madhya Pradesh, Bihar and Jharkhand. States like Kerala and Punjab experi-ence relatively lower levels of undernutrition.

We have used CCs and CI to assess the inequalities in the dis-tribution of water, sanitation and health deprivations. As discussed earlier, the CC plots the cumulative proportions of the population—beginning with the most disadvantaged in terms of income and ending with the least disadvantaged—on the X axis against the cumulative proportions of ill health on Y axis. For interpretative purposes, if the burden of deprivation, for example child undernutrition, is equally distributed across socioeconomic groups, CC will coincide with the diagonal. If deprivation is concentrated in the lower socioeconomic


Tab

le 5

.1:

Uns

afe

Wat

er, S

anit

atio

n an

d U

nder

wei

ght C

hild

ren

(in

%)

and

Ineq

ualit

ies

in 1

8 St

ates

of I

ndia

(20

05–0

6)

Uns

afe W

ater

(W),

Sani

tatio

n (S

) and

Und

erw

eigh

t (U

) C

once

ntra

tion

Indi

ces (

CI)

Stat

esW

(% h

hs)

S (%

hhs

)U

(% ch

ildre

n)C

I (W

)C

I (S)

CI (

U)

And

hra

Prad

esh

2472

33–0

.274

–0.2

06–0

.161

Ass

am45

7736

–0.2

08–0

.171

–0.1

29B

ihar

9387

56–0

.027

–0.1

12–0

.095

Chh

attis

garh

5186

47–0

.168

–0.1

15–0

.112

Guj

arat

656

45–0

.597

–0.3

59–0

.145

Har

yana

3562

40–0

.172

–0.2

69–0

.140

Jhar

khan

d66

8657

–0.1

81–0

.125

–0.0

88K

arna

taka

2671

38–0

.257

–0.2

12–0

.158

Ker

ala

1312

23–0

.187

–0.4

81–0

.225

Mad

hya

Prad

esh

4182

60–0

.263

–0.1

61–0

.079

Mah

aras

htra

969

37–0

.483

–0.2

42–0

.192


Oris

sa77

8941

–0.1

27–0

.091

–0.1

80Pu

njab

4354

25–0

.196

–0.3

06–0

.263

Raj

asth

an30

8240

–0.2

61–0

.154

–0.1

30T

amil

Nad

u8

7830

–0.2

11–0

.161

–0.1

86U

ttar

Pra

desh

8780

42–0

.084

–0.1

60–0

.119

Utt

aran

chal

3156

38–0

.269

–0.3

23–0

.207

Wes

t Ben

gal

6672

39–0

.196

–0.1

83–0

.161

All

Indi

a44

7343

–0.2

65–0

.210

–0.1

58So

urce

: II

PS a

nd M

acro

Inte

rnat

iona

l (20

07).

Not

es:

Safe

wat

er i

nclu

des

pipe

d w

ater

sup

ply,

bot

tled

wat

er a

nd w

ater

con

sum

ed a

fter

any

kin

d of

tre

atm

ent

or p

urifi

catio

n w

here

as

adeq

uate

sani

tatio

n in

clud

es la

trin

e/to

ilet f

acili

ty a

ttac

hed

to a

pro

per s

ewer

syst

em.

%

hhs

: per

cent

age

of h

ouse

hold

s.


groups, CC lies above the diagonal. The farther the CC is from the diagonal, the greater would be the degree of inequality. CCs at the aggregate national level for all the three indicators are plotted in Figure 5.3. All these CCs lie above the line of equality indicating that there is a greater concentration of water, sanitation and health deprivations among the poorer groups.

Figure 5.3: Concentration Curves for Inadequate Water, Sanitation and Underweight Children


Further, Table 5.1 presents the computed CI for the selected deprivation indicators across all the major Indian states. As mentioned earlier, the CI measure ranges between –1 and +1. If CI is negative then it implies that deprivation is concentrated among the poorer sections of the population. Also, larger CI value implies greater inequality and greater concentration of deprivation among the poor. Based on these computations, it is inferred that in all states the CI values for water, sanitation and underweight outcomes are negative indicating that


deprivations manifest along the income domain and are concentrated among the poor.

All-India level inequalities are more pronounced in case of inad-equate and safe water as these have higher CI values. While the CI value for inadequate and safe water at the national level is computed to be –0.265, it presents a wider range of inequalities across various states with the minimum of –0.027 in Bihar and –0.597 in Gujarat. Among other major states, Maharashtra and Andhra Pradesh experience greater income-related inequalities in distribution of inadequate safe water as against the states of Uttar Pradesh and Orissa with relatively low inequalities. Similarly, inadequate sanitation is observed to be most unequally distributed in the states of Kerala (–0.481) and Gujarat (–0.359). From a policy perspective, it reveals the magnitude of the problem and clearly, in this case, refl ects many disappointments.

As regards nutritional makeup in terms of underweight outcomes, inequalities at the all-India level are computed to be –0.158. The larg-est inequality according to this criterion is observed in Punjab (–0.263) and the least is in Madhya Pradesh (–0.079). The richer states (such as Kerala [–0.225] and Maharashtra [–0.192]) depict higher inequali-ties but poorer states (such as Orissa [–0.180]) also possess signifi cant income-related inequities. Moderate range of inequality in under-weight outcomes across other poorer states such as Madhya Pradesh, Jharkhand, Bihar, Chhattisgarh and Uttar Pradesh could possibly be conditioned by the level of overall prevalence of the same.

However, there is a strong inverse relationship between the ranking of states based on underweight children and by the CI (underweight children). Spearman’s rank correlation coeffi cient, computed for the two sets of rankings, is highly negative, at 0.825 (signifi cant at 1 per cent level). Interestingly, the best two states in terms of average inci-dence turn out to be the worst two on equity front, whereas the worst four performers on average incidence emerge to be more equitable. With the exception of Assam, it appears that equity gets compromised while progressing towards reduction of undernutrition.

The foregoing analysis gives an indication that income is an import-ant variable, along with which inequalities in nutritional status are getting manifested. Income status of the household helps to raise nutritional status of children through the purchase of food, medicines


and access to healthcare. Apart from income, maternal education certainly emerges to be an important factor creating differences in nutritional status of the children.

The maternal education indicator refl ects on empowerment of women and her share in household resource allocation. In Table 5.2, we present the distribution of underweight children according to mother’s education and WSH condition of the household. It can be observed that at the all-India level, around 60 per cent of the under-weight children belong to mothers with no education and it shows a rapid decline as we move to better educational categories. In states like Bihar, Rajasthan, Uttar Pradesh and Jharkhand, this proportion is well above 70 per cent. Only in Kerala do underweight children belong mainly to mothers with better educational backgrounds.

The last two columns of Table 5.2 indicate that around 80 per cent of the underweight children belong to households with inadequate WSH conditions. This proportion is well above 90 per cent in case of Bihar, Orissa, Jharkhand and Uttar Pradesh. The results clearly indicate that children belonging to poor households are deprived not only because of the low income of their families but also poor educational status of mothers and unhygienic conditions prevailing in the household. It implies that if interventions are simultaneous, then greater improvements in the nutritional and health status of children could be achieved.

CONCLUSION This chapter examines the association between inadequate water-sanitation provisions and childhood undernutrition. With the help of a simple framework three exogenous pathways, namely physical–environmental features, household-related aspects and community specifi c-effects, are identifi ed to determine the nutritional health of children. Water and sanitation is identifi ed to cross-cut across these pathways and increase the risks of childhood ailments. Further, using NFHS-3 (2005–06) data we present some evidence on shortfalls in the provisioning of safe water and sanitation facilities across Indian states. For analytical purposes, this study defi nes safe water to include sources such as piped water supply, bottled water and water consumed


Table 5.2: Underweight Children According to Maternal Education and WSH Conditions

Mother’s Educational Background Inadequate WSH

States Illiterate Primary Secondary Higher Water Sanitation

Andhra Pradesh 47 22 30 1 38 75Assam 46 24 30 1 93 78Bihar 76 9 14 1 97 89

Chhattisgarh 61 21 17 1 91 92Gujarat 46 14 38 3 38 65Haryana 47 14 36 3 50 65Jharkhand 72 11 16 1 95 92Karnataka 45 14 38 3 55 78Kerala 2 7 75 15 77 24Madhya Pradesh 62 18 18 2 83 87Maharashtra 31 13 53 3 32 63Orissa 57 21 22 1 97 96Punjab 52 18 28 3 52 55Rajasthan 79 10 10 2 65 87Tamil Nadu 23 27 46 4 14 76Uttar Pradesh 73 9 17 2 94 85Uttaranchal 56 12 27 5 38 65West Bengal 53 23 23 1 87 76All India 60 14 24 2 76 81


after any kind of treatment or purifi cation and adequate sanitation to include latrine/toilet facility attached to a proper sewerage system. Using these defi nitions, it is observed that in all of India, 44 and 73 per cent of surveyed households do not have access to adequate water and sanitation facilities, respectively. A region-wise scrutiny suggests a desolate picture of the distribution of water and sanitation facilities with a greater burden of deprivations observed among the econom-ically backward states.

The study emerges with vital evidence on the linkage between inadequate water and sanitation facilities and prevalence of childhood undernutrition in households. In particular, we notice that around 80 per cent of the underweight children belong to households with


inadequate water and sanitation facilities. This proportion is well above 90 per cent in case of Bihar, Orissa, Jharkhand and Uttar Pradesh. This chapter also contributes to the literature on water and sanitation by adopting an equity perspective. The study fi nds alarming concen-tration of undernutrition and unsafe water and sanitation facilities among households belonging to lower socioeconomic status. Based on the inequality measures (CIs), it is inferred that in all the states the CI values for water, sanitation and underweight outcomes are negative, indicating that deprivations manifest along income domain and are concentrated among the poor. It is worth highlighting here that the inequality levels are higher with better levels of nutritional achievement. Undoubtedly, from a policy perspective, inequality-aversion measures need to be promoted in income-rich states where more and more concentration of this misfortune among the poor could be avoided, whereas greater attention needs to be laid towards improving the general child health conditions in backward states. Given the fact that a large number of the Indian households do not have access to safe water and sanitation and are vulnerable to several other determinants, including household hygiene, better education, particularly maternal education, and awareness can be effective in reducing their impact on child health.

Our analysis indicates the benefi ts of maternal education on child’s health and notes that the prevalence of undernutrition is very low in cases where mothers have received higher education (secondary plus). Clearly, the distribution of individual characteristics like maternal education along with safe sanitation emerges as the infl uencing factors shaping the rich–poor divide in child nutrition. As a policy pointer, this observation calls for bridging the specifi c characteristic divide between the poor and the rich to minimise the gap in child health outcomes.

In conclusion, it is essential to reiterate that poor child health and nutrition endangers the development of basic capabilities and func-tioning and disregards the child’s right to lead a healthy life. Given its nontrivial implications, many governmental organisations and NGOs have initiated several activities to reduce the problem. It is important that these efforts perceive the problem in a multidimensional sense and discern the role of various determinants for effective policymaking.


An improved understanding of the complex social reality helps in executing more effi cient health interventions and in prioritising these interventions. It may be emphasised that addressing the issues of access to safe water and sanitation not only widens the interpretation of poverty but also attaches greater relevance to the problem from the perspective of social justice and equity.

APPENDIX

Measuring Nutritional StatusAnthropometric data on the weight-for-age of children under the age of fi ve were used to assess their nutritional status. Weight-for-age z-scores were calculated as the difference between the child’s weight and the median weight of children of the same age and sex in a healthy reference population, divided by the standard deviation of that reference population. The growth standards used in NFHS-3 are formed on the basis of the new international reference population released by WHO in April 2006 (WHO 2006) and accepted by the Government of India (IIPS and Macro International 2007). In the descriptive analysis, a child is considered underweight if it falls two standard deviations below the median score for children of the same age and gender in the reference population.

Income-related Health InequalitiesThe Concentration Curve (CC) and the Concentration Index (CI) are employed here as a means for quantifying the degree of income-related inequality in certain specifi c health variables. The CC plots the cumulative proportions of the population—beginning with the most disadvantaged and ending with the least disadvantaged in terms of income) along the X axis against the cumulative proportions of ill health plotted on the Y axis. For interpretative purposes, if the burden of ill-health were equally distributed across socioeconomic groups, CC would coincide with the diagonal. If poor health is concentrated in the lower socioeconomic groups, the health CC would lie above the diagonal and the farther the CC lies from the diagonal, the greater would be the degree of inequality. CI is defi ned as twice the area between the CC and the diagonal. CI provides a measure of the extent of inequalities in health status systematically associated with socioeconomic status. For computational purposes, CI could be written in many ways (Wagstaff et al. 1991, Kakwani et al. 1997), one being


(1)

C =n

h Rii=

n

i1 2.

11

− −∑μ ( )

where ‘h’ is the health variable whose inequality is being measured, ‘µ’ is its mean, ‘Ri’ is the ‘i’th individual’s fractional rank in the socioeconomic distribution. The CI ranges between +1 and –1 with negative values indicat-ing ill-health outcomes to be disproportionately concentrated among the poor and vice versa.

Data and VariablesThis study uses the National Family Health Survey-3 (NFHS-3) data pro-vided by the International Institute for Population Sciences (IIPS) and Macro International. For NFHS-3, approximately 124,000 ever-married women 15–49 years old were surveyed. For each state, a multi-stage, systematic, stratifi ed sampling design was adopted, where the primary sampling units were selected systematically, with probability proportional to size. House-holds were then sampled using systematic sampling with equal probability, and all eligible women in every household were interviewed. National and state level sampling weights were created to refl ect sampling design (IIPS and Macro International 2007). For NFHS-3, 46,655 children aged less than fi ve years could be analysed. For computing the concentration index, the weight for age z-score of children was classifi ed into a binary variable with children above a z-score of (–2) standard deviation to be considered as undernourished. Further, households are ranked in terms of the wealth index factor score provided in NFHS-3 dataset. NFHS-3 wealth index is used as a proxy for income so as to designate an economic rank to the households. This wealth index is constructed using the principle component analysis, which includes 33 assets and housing characteristics on which information was obtained (IIPS and Macro International 2007). The use of an asset index to capture socioeconomic status has its shortcomings, but in the absence of reliable information on income or expenditure, the use of such an asset index is generally a good alternative to distinguish socioeconomic layers within a population.

REFERENCES

Ahmed, N.U. M.F. Zeitlin, A.S. Beiser, C.M. Super, and S.N. Gershoff. 1993. ‘A Longitudinal Study of the Impact of Behavioural Change Intervention on Cleanliness, Diarrhoeal Morbidity and Growth of Children in Rural Bangladesh’, Social Science and Medicine, 37(2): 159–71.


Cairncross, S. and V. Valdmanis. 2006. ‘Water Supply, Sanitation and Hygiene Promotion’, in D. Jamison, J.G. Breman, A.R. Measham, G.Alleyne, M. Claeson, D.B. Evans, P. Jha, A. Mills, and P. Musgrove (eds) Disease Control Priorities in Developing Countries, 2nd edn. Washington, D.C.: World Bank.

Checkley, W., R.H. Gilman, R.E. Black, L.D. Epstein, L. Cabrera, C.R. Sterling, and L.H. Moulton. 2004. ‘Effect of Water and Sanitation on Childhood Health in a Poor Peruvian Peri-urban Community’, Lancet, 363(9403): 112–8.

Esrey, S.A. 1996. ‘Water, Waste, and Well-being: A Multi-country Study’, American Journal of Epidemiology, 143(6): 608–23.

Esrey, S.A., J.P. Habicht, and G. Casella. 1992. ‘The Complementary Effect of Latrines and Increased Water Usage on the Growth of Infants in Rural Lesotho’, American Journal of Epidemiology, 135(6): 659–66.

Fewtrell, L., A. Prüss-Üstün, R. Bos, F. Gore, and J. Bartram. 2007. Water, Sanita-tion and Hygiene: Quantifying the Health Impact at National and Local Levels in Countries with Incomplete Water Supply and Sanitation Coverage. Environmental Burden of Disease Series No. 15. Geneva: World Health Organization.

Gundry, S., J. Wright, and R. Conroy. 2004. ‘A Systematic Review of the Health Outcomes Related to Household Water Quality in Developing Countries’, Journal of Water and Health 2(1): 1-13.

Hunter, P.R., M. Waite, and E. Ronchi (eds). 2003. Drinking Water and Infectious Disease: Establishing the Links. London: CRC Press and IWA Publishing.

-IIPS and Macro International. 2007. National Family Health Survey (NFHS-3), 2005–06. Mumbai: International Institute for Population Sciences.

Jalan, J. and M. Ravallion. 2003. ‘Does Piped Water Reduce Diarrhoea for Children in Rural India?’, Journal of Econometrics, 112(1): 153–73.

Kakwani, N.C., A. Wagstaff and E. van Doorslaer. 1997. ‘Socioeconomic Inequali-ties in Health: Measurement, Computation and Statistical Inference’, Journal of Econometrics, 77(1): 87–104.

Murray, C.J.L. and A.D. Lopez . 1996. ‘Global Health Statistics: A Compendium of Incidence, Prevalence and Mortality Estimates for over 200 Conditions.Cam-bridge: Harvard School of Public Health, Geneva: World Health Organization, and Washington, D.C.: World Bank.

Prüss-Üstün, A. and C. Corvalán. 2006. Preventing Disease through Healthy Envi-ronments: The Contribution of Water, Sanitation and Hygiene. Geneva: World Health Organization.

Prüss-Üstün, A., D. Kay, L. Fewtrell, and J. Bartram. 2004. ‘Unsafe Water, Sanita-tion and Hygiene’, in M. Ezzati, A.D. Lopez, A. Rodgers, C.J.L. Murray (eds). Comparative Quantifi cation of Health Risks. Global and Regional Burden of Dis-ease Attributable to Selected Major Risk Factors. Vol 1. Geneva: World Health Organization.

Sen, A. 1999. Development as Freedom. New York: Oxford University Press.———. 2002. ‘Why Health Equity’, Health Economics, 11(8): 659–66.Wagstaff, A, P. Paci, and E van Doorslaer. 1991. ‘On the Measurement of Inequali-

ties in Health’, Social Science and Medicine, 33(5): 545–57.


Wagstaff, A. and N.N. Nguyen. 2003. ‘Poverty and Survival Prospects of Vietnam-ese Children under Doi Moi’ in P. Glewwe, N. Agrawal, and D. Dollar (eds), Economic Growth, Poverty and Household Welfare: Policy Lessons from Vietnam. Washington, DC: World Bank.

WHO. 2002. World Health Report 2002: Reducing Risks, Promoting Healthy Life. Geneva: World Health Organization.

———. 2006. WHO Child Growth Standards: Length/Height-for-age, Weight-for-age, Weight-for-length, Weight-for-height and Body Mass Index-for age—Methods and Development. Multicenter Growth Reference Study Group, Geneva: World Health Organization.

WHO/UNICEF. 2004. Meeting the MDG Drinking Water and Sanitation Target: A Mid-Term Assessment of Progress. Geneva, World Health Organization.

6

Access to Safe Water and Health

Mortality, Morbidity and Malnutrition in Nepal

ANNETTE L FITZPATRICK, MEERA KANSAKAR, JASON SOH, PAM ELARDO, KEVIN C FITZPATRICK

AND DIBYA R KANSAKAR1

INTRODUCTION

ACCESS TO A SAFE drinking water and sanitation services is fundamental to improving the health of a nation. Lack of such basic services substantially contributes to the high burden of disease and mortality in developing countries like Nepal.

Nepal, in both comparative and absolute terms, is among the poorest and least developed countries of the world. The life expectancy has increased in recent years to 64 years, but it is still behind the average worldwide life expectancy of 69 years. Nepal’s infant mortality rate of 47 per 1,000 live births is among the highest in the region (World Bank 2009). While considerable progress has been made over the last decade towards reducing poverty and improving health, over 30 per cent of the people in the country still live below the current poverty level. Gender disparities are common with lower life expectancy for women, and only 26 per cent women are literate compared to 62 per cent men. Decline in poverty has been accompanied by an increase in inequality and rise in disparities between urban and rural regions and between different castes.

1 We gratefully acknowledge the support of Puget Sound Partners for Global Health, Seattle, WA and the National Institutes of Health, National Center on Minority Health and Health Disparities (T37-MD001449) to this project.

116 Annette Fitzapatrick et al.

While service levels of water supply vary considerably across Nepal, much of the country remains at the basic or below average level (GoN 2008). An August 2008 report states that 77 per cent of the people have access to basic facility of drinking water and 46 per cent are provided with basic sanitation services (GoN 2008). The water supplied does not meet the national or WHO standards of quality and does not reach homes or household compounds. Often water supply is available only for four hours a day.

There are many challenges to providing clean water in Nepal. Based on the assessments made by the Ministry of Physical Planning and Works (GoN 2008), the following serious challenges need to be considered:

1. There is a lack of clarity in the roles of sector agencies leading to confusion during project planning and implementation.

2. Coordination between sector agencies is generally poor, and decision-making at the centre slow. Consequently, implemen-tation is delayed or is ineffective.

3. Municipalities are not empowered to implement and manage schemes effectively.

4. The services are not cost-effective and the municipal suppliers cannot recover costs from the community. Thus the poor and marginalised groups are not adequately served.

5. The fi nancial burden on municipalities is high, as they take loans to build the infrastructure to provide water and sanitation as a service. Complicated implementation procedures involving multiple stakeholders add to the complexity of the process.

6. Private sector operators are unwilling to take on operation and management of urban schemes as tariff collection and associated income do not guarantee a working profi t.

7. Poor monitoring and evaluation of urban water supply and sanitation projects prevents accurate coverage and creates dif-fi culty in obtaining performance data

This chapter describes access to water and health services in Nepal and the efforts made by the government to address the crisis. It further presents results of a survey of two villages in the Terai region using

Access to Safe Water and Health 117

epidemiologic methodology for determining mortality, morbidity and childhood malnutrition.

Water Access and Health Issues in Nepal

Health statistics in Nepal are primarily collected by the government based on admissions and visits made at hospitals and health clinics. The institutions involved in the delivery of basic health services during 2002–03 included 84 hospitals, 188 primary health centres (PHCs), 697 health posts and 3,129 sub-health posts (GoN 2008). While monitoring of specifi c health conditions between 2002 and 2003 has shown overall reductions in malnourished children under age three from 18.3 per cent in 2002 to 14 per cent in 2003, undernutrition remains a serious problem even now. Diarrhoeal diseases are also a major health problem with a national ranking of second- or third-most prevalent disease in 2002 and 2003 respectively (GoN 2008). New cases of diarrhoeal diseases increased over this period from 177 to 200 per 1,000 children under the age of fi ve. However, some health parameters have improved. Since 1990 infant mortality has been cut by half to 48 per 1,000 live births in 2006. Tangible reduc-tions in underweight and stunted children have also been reported (Table 6.1).

Recognising the fact that access to safe drinking water and sanita-tion facilities, along with hygienic practices, can drastically reduce the high rate of water-related illness and deaths, the Government of Nepal has given high priority to this sector in its policy and planning. In addition to endorsing the Millennium Declaration in September 2000, it has committed itself to achieve MDGs by 2015. Although MDGs have set quantitative poverty reduction targets, many of them are also directly or indirectly linked to access to drinking water and sanitation development. The MDGs are to be measured in terms of outcome and impact indicators. Nepal recognised that the MDGs may not be attained without on-going efforts through the three Five Year Plan periods. In 2001, Nepal prepared its Poverty Reduction Strategy Paper, which incorporated most of the MDG-related indicators. This itself became the government’s 10th Plan document for the period 2002–07 (GoN 2005). The specifi c targets for this plan period were compatible with the MDGs.


Tab

le 6

.1:

Tre

nds

in W

ater

Acc

ess,

San

itat

ion

and

Hea

lth

Par

amet

ers

in N

epal

(19

90–2

006)

1990

1995

2000

2005

2006

Sust

aina

ble

acce

ss to

wat

er (%

)46

7073

8189

Sust

aina

ble

acce

ss to

sani

tatio

n (%

)6

2230

3941

Popu

latio

n be

low

min

imum

die

tary

ene

rgy

cons

umpt

ion

(%)

4947

–40

40U

nder

wei

ght c

hild

ren

[age

6–9

mon

ths (

%)]

57–

53–

49St

unte

d ch

ildre

n [(

Age

6–9

mon

ths (

%)]

60–

55–

46In

fant

mor

talit

y ra

te (p

er 1

,000

live

birt

hs)

108

7964

5148

Mor

talit

y ra

te u

nder

age

5 (p

er 1

,000

live

birt

hs)

162

118

9165

–

Sour

ce:

GoN

(200

7).


The 10th Plan recognised the role of local bodies, community organ-isations, and non-governmental organisations (NGOs) in development and refl ected the government’s commitment to decentralisation and functional devolution in all sectors, including drinking water, sanitation and health. The plan sought to increase access of social service and basic facilities like safe drinking water and sanitation to deprived communities such as the Dalits and Janajatis—groups pegged lowest in the social hierarchy—who are not reached by any develop-ment investment programmes. Two policy decisions were taken to facilitate changes in the drinking water and sanitation sector.

1. Revision of the National Water Supply and Sanitation Policy (1998), in order to clearly defi ne the roles and responsibilities of different stakeholders, including local bodies, community organisations and benefi ciaries, in planning and upkeep of water supply and sanitation services.

2. Abolition of district offi ces of the Department of Water Supply and Sanitation (DWSS) and their reorganisation as ‘facilitators’ and ‘monitors’ of small projects, and ‘planners’ and ‘implementers’ of larger schemes.

The Nepal government has striven to achieve these goals through decentralised demand-driven approaches and the involvement of NGOs and other support organisations to plan and implement actions demanded by local communities. The communities are made responsible for the operation and management of the developed programmes. Also, under a new policy, sanitation has been made an inalienable component of new drinking water projects (GoN 2007a). Furthermore, this new policy aims to develop national water quality standards or guidelines and strengthen water quality monitoring to address the issues of arsenic and other anthropogenic contaminations found in some shallow groundwaters in the Terai region.

As water and health are intrinsically linked, the Second Long Term Health Plan (SLTHP) 1997–2017 provided the road map for substan-tial investment in the health sector. The objective was to have

a health system in which there is equitable access to coordinated quality healthcare services in rural and urban areas, characterised by


self-reliance, full community participation, decentralisation, gender sensitivity, effective and efficient management and private and NGO sector participation in the provision and fi nancing of health services resulting in improved health status of the population.

Targets for these policies are shown in Table 6.2 Government of Nepal has pursued a policy to decentralise man-

agement of health facilities by putting communities in charge of the institutions. The government handed over 1,114 sub-health posts in 25 districts (GoN 2005), resulting in an increase in the availability of health facilities compared to the Ninth Plan period. The move also resulted in decrease in travel time to reach health facilities. Access to health posts and hospitals within 30 minutes of travel increased signifi cantly—62 per cent households in 2007 compared to 45 per cent in 1996. However, the number of health facilities declined from 4,429 in 2001–02 to 4,408 in 2002–03 and 4,401 in 2003–04 (GoN 2003, 2004). The long political unrest in Nepal since1997 which still continues has resulted in destruction and damage to these facilities. The Nepal government has welcomed efforts from the civil society, primarily NGOs, on issues of water access and health. The Rural Water Supply and Sanitation Fund Development Board (RWSSFDB) is a semi-autonomous body that funds and supervises NGOs to help com-munities form user groups to build, manage and maintain their own water systems. The RWSSFB fully recognises the central role of women in supplying their families with water for drinking and domestic use. Therefore inclusion and empowerment of women is a key objective. Although this intervention has signifi cantly empowered women as well as men, studies have shown that Brahman and Chhetri (high castes) households get more than their proportional share of access to the RWSS facilities compared to Dalits and Janajatis (GoN 2005).

CASE STUDY Profi le of Dhanusha District

The area of the study, Dhanusha district, lies in the Terai region, the southern plains of Nepal, located at the foot of the Himalayan range.


Tab

le 6

.2:

Pro

gres

s an

d T

arge

ts fo

r H

ealt

h du

ring

the

10th

Pla

n P

erio

d

Goa

l

Base

Per

iod

of

the 1

0th

Plan

(2

001/

2002

)

10th

Pla

n T

arge

t∗ 2

006/

07M

DG

Tar

get

2015

Prog

ress

in

2006

/200

7N

orm

al C

ase

Low

er C

ase

Infa

nt m

orta

lity

rate

per

1,0

00 b

irths

64.2

4547

2648

#U

nder

5 m

orta

lity

per 1

,000

birt

hs91

.272

54M

ater

nal m

orta

lity

rate

per

100

,000

live

birt

hs41

530

031

514

5N

ALi

tera

cy ra

te 1

5+ y

rs (%

)44∗∗

6361

100

53.7

#Fe

mal

e lit

erac

y ra

te 1

5+ y

rs (%

)35

.655

5310

042

.5#

Net

enr

olm

ent i

n pr

imar

y sc

hool

s (%

)80

.490

8910

087

.4#

Acc

ess t

o sa

fe d

rinki

ng w

ater

faci

lity

(%)

71.6

8583

100

77#

Acc

ess t

o sa

nita

tion

faci

lity

(%)

46#

Mal

nour

ished

chi

ldre

n un

der 5

(%)

48.2

––

2849

#H

ead

coun

t pov

erty

(%)

3830

3321

–

Sour

ce:

GoN

(200

7a).

∗

The

10t

h Pl

an h

as tw

o sc

enar

ios:

norm

al c

ase

(pea

ce) a

nd lo

wer

cas

e (c

ontin

ued

confl

ict)

.

∗∗ A

dult

Lite

racy

Rat

e ha

s bee

n re

vise

d fr

om 4

9.2%

to 4

4 %

(GoN

200

5).

#

GoN

(200

7a).

N

A N

ot A

vaila

ble.


The Terai has a tropical to sub-tropical climate. Janakpur town, the administrative headquarters of Dhanusha district, lies southeast of Nepal. The lower caste communities in the region under study—Mujeliya and Rajaulnumber around 1,800 and are the poorest in Nepal. They often do not own any land and survive on daily wages. These groups are often overlooked by normal development pro-grammes in thecountry. In terms of different caste and ethnic groups, Hill and Terai Dalits represent the poorest segment of the population, despite reductions in poverty from 42 per cent to 31 per cent between 1996 and 2004 (World Bank 2009).

In Dhanusha district, local trends are similar to those recorded at the national level. According to a 2005 report of the Department of Health Services, the three most common illnesses reported during 2001–02, based on the number of visits to regional health clinics in Dhanusha, were skin diseases, accounting for 7.9 per cent of the visits, followed by intestinal worms (4.0 per cent) and diarrhoeal disease (3.1 per cent). Malnourishment, based on weight-for-age, reached almost 19 per cent (GoN 2004). These conditions, along with other water-borne and infectious diseases that plague the nation, are among those highly correlated to the lack of access to clean water and sanitation.

In the study conducted in 2004–05 by the University of Washington, Seattle, WA, a total of 335 households were surveyed and we received a response rate of 99.7 per cent from households in the targeted com-munity. These households represented a total of 1,781 individuals for whom health status was collected (Figure 6.1). Overall, almost half of the household members were adults under age 60 with 49 per cent females. About 17 per cent were children under age six, 18 per cent were children aged between 6–11 years, and 11 per cent were between 12–17 years. While over half of the children of 6–18 years of age had some formal education, only about 25 per cent of adults had any schooling. While 47 per cent of men were literate, only about 22 per cent of women self-reported the ability to read and write, far below national female literacy levels of 42.5 per cent (GoN 2007a).

Water sources and access to latrines prevalent at the time of the health survey is provided in Table 6.3. Almost 60 per cent of house-holds already had access to deep water tubewells provided by an NGO (Living Earth Institute 2009), although none functioned for more than a few months. Prior to the intervention, almost all villagers


Figure 6.1: Number of Family Members Evaluated for Health Status among Mujelia and Rajaul Communities

Table 6.3: Access to Water and Latrines in the Study Area

Number %

Source of waterDeep water tubewellShallow tubewells provided by government

198137

59.740.3

Source of water prior to well accessShallow tubewells provided by government 335 100.0

Availability of latrine to household members AvailableNot available

104231

31.069.0

Usual location to urinate or defecate∗In one’s own or privately-owned fi eldsNearby public land By the roadsideBy the pond or streamsideMore than one of the above

22 91 35 26 25

11.145.717.613.012.6

∗Responses from 199 respondents without access to a latrine

were drinking water from shallow wells provided by government. Thirty-one per cent households had already built latrines based on a concrete pit and pan provided by the NGO. Those who did not have, used the nearby public or private land.


METHODOLOGY

This study was conducted as a baseline survey to evaluate the health of residents living in Mujeliya and Rajaul villages, under Janakpur Municipality in Dhanusha district prior to completion of a programme by the Living Earth Institute (LEI) on providing access to clean water to villagers (Living Earth Institute 2009). This health survey was administered at the early stages of the programme in order to assess morbidity and mortality rates of the community before full benefi ts of clean water access could be realised. Door-to-door interviews for infor-mation on the health status of household members were conducted with the consenting households between September 2004 and January 2005. Anthropometric measurements of children living at home were also made at the time of the interviews.

Data Collection

Mortality and MorbidityThe survey instrument in English was developed based on a literature review of similar instruments designed to collect self-reported health data. All questions were reviewed by a local physician aware of the living conditions in the targeted villages. Questions were subsequently worded to ascertain the number of deaths occurred in each household in the fi ve years before September 2004 and a history of each household member’s health, including information on polio or fi lariasis cases. The survey also evinced information on the occurrence of different diseases or symptoms during the previous six months like jaundice, typhoid, malaria, kalazar, intestinal worms, pneumonia, fever, skin conditions such as rashes, itching and skin infections, eye problems such as red eye, itching or swelling or discharge or infections) or other major illnesses. Data on the number of episodes of Diarrhoea that occurred in the month before the interview, defi ned as three or more loose/liquid stools per day, was also collected. The respondent was asked to provide cause of death, if known, for any reported mortalities. Enumeration of all household members was conducted to include information on age, level of education completed, literacy and occupation—where applicable).


Interviews were conducted by members of the Women Develop-ment Service Centre (WDSC), a local NGO located in Janakpur dedicated to improving the health and economic situation of local women and their families. Field investigators, six women and one man, were members of the local community and well-known to potential respondents, thus helping to ensure maximum participa-tion in the study. A training session and pre-test of the protocol was held in August 2004 to review the survey instrument and provide instruction to interviewers. Survey instrument was modifi ed based on these preliminary exercises. The interviews were conducted in the local language Maithili, with Nepali text written on the questionnaire. Household surveys were conducted from September 2004 to January 2005 and regularly monitored by Nepali study coordinators.

AnthropometryIn order to assess issues of malnutrition, stunting and developmental problems, and measurements of weight, height and head circumference were taken of children 14 years of age or younger, who were part of the household and present at home during the survey. Field investi-gators carried with them a standard household scale with the ability to measure weight to the nearest 0.5 kg. Height and head circum-ference was measured to the nearest centimetre using a standard cloth tape.

Informed ConsentPrior to conducting the survey, fi eld investigators read out the consent forms to the head of the household in Maithili. Consent was provided by either signature or thumb print on the form. Children, with guid-ance from adults, also completed an informed assent form prior to being measured. For this study, Institutional Review Board (IRB) approvals were received from the University of Washington, Division of Human Subjects and the Nepal Health Research Council.

Integration of MethodsField investigators visited the assessment areas in teams of two, one to conduct the survey and the other to record responses. After explaining the purpose of the study and collecting informed consent, the medical


history questionnaire, containing questions on recent mortality and morbidity of family members, was given and responses received on hard copy. The forms and copies were later processed by WDSC.

Statistical AnalysesUsing total number of persons in households surveyed as the denomi-nator, mortality rates and rates of individual diseases or symptoms were calculated. Comparisons were made with rates of diseases reported by the Nepali government utilising data reported in the 2002–03 Annual Report of the Department of Health Services (GoN 2007b).

In order to assess malnutrition, stunting and developmental prob-lems, standardised databases developed by the Center for Disease Control and Prevention (CDC) and WHO were accessed and merged with study data (CDC 2005). These data provide a reference in terms of standard deviations from the mean, against which each child’s height-for-age (HA), weight-for-age (WA), weight-for-height (WH), and head circumference (HC) could be compared. The distribution of the indices expressed in terms of Z scores, and also referred to as standard deviation (SD) units, was used in these analyses. Using these standardised Z scores, nutritional indices were calculated: ≥ –1 as normal or above normal; between –1 and –2 as mildly malnourished (WH), mildly stunted (HA) and with mild developmental problems (HC); between –2 and –3 as malnourished (WH), stunted (HA) and with developmental problems (HC); and < –3 as severely malnour-ished (WH), severely stunted (HA) and with severe developmental problems (HC). All data were analysed using the Statistical Package for the Social Sciences (SPSS, Inc., Chicago, IL).

FINDINGS

Ideally, for such a study, health of persons with and without access to water and sanitation needs to be studied, but as the data was col-lected approximately at a time when wells and latrines had just been provided to the community, this was not possible. The data collected serve as baseline statistics and provides information on mortality and health status when access to clean water is not available. The data also represent health parameters that can be collected easily by others while conducting water access projects.


Mortality

Based on data collected in the household interviews, 95 deaths had occurred over a fi ve-year period representing 5.1 per cent of the population or 10 deaths per 1,000 person-years (Table 6.4). Almost half (49 per cent) of the deaths were among adults aged 60 years or more, 24 per cent among adults aged 18–59 years, 19 per cent among children under six years and 7 per cent among children between 6–11 years. Mortality rates were estimated to be 12 per 1,000 person-years for children aged below six, and fi ve or less for older children and adults through 59 years. Adults aged 60 and above had the highest mortality rate estimated at 105 per 1,000 person-years. Although 29 per cent deaths were due to unknown causes, 17 per cent were related to respiratory symptoms and pneumonia, 14 per cent to cardio-vascular diseases, including sudden death, 10 per cent to stomach prob-lems and Diarrhoea and fi ve per cent due to ‘witchcraft’ (Table 6.5). The percentage of deaths due to Diarrhoea/digestive causes was about twice that of the national average. Mortality due to respiratory causes was about 50 per cent higher than the national fi gure. This data is based on deaths reported by household members themselves.

Table 6.4: Deaths Occurred from 1999–2004 in Mujeliya and Rajual villages, Janakpur Municipality, Nepal with total population 1,781.

Age of Resident Reported Deaths (N) %Rate per 1,000

Person-years

ChildrenUnder 6 years 18 18.9 126–11 years 2 2.1 112–17 years 5 5.3 5Total Children (25) (26.3) (6)

Adults18–59 years 23 24.2 560+ years 47 49.5 106Total Adults (70) (73.6) (15)TOTAL 95 100.0 11

Morbidity

Within a month Diarrhoea affected about twice as many children under age six (21 per cent) compared to all other age groups (10–11 per cent)


Table 6.5: Causes of Deaths Reported by Heads of Households in Mujeliya and Rajual Villages Between 1999 and 2004

Causes of Deaths Self-reported (%) National Report (%)

Asthma/Pneumonia 16.8 10.9Diarrhoea/Digestive 10.5 4.8‘Sudden Death’ 7.4Heart/BP/Diabetes 6.3 4.2Pain/Paralysis 5.3Witchcraft* 5.3Epilepsy 4.2Kalazar 3.2Body swelling 3.2Accident 3.2Old age 2.1 24.5Jaundice/Hepatitis 1.1 1.3Cancer 1.1 3.6Pregnancy/Childbirth 2.2 5.0Unknown 29.5

∗The term ‘witchcraft’ was provided by interviewees without explanation.

as shown in Table 6.6. The number of disease episodes was higher in children under age six compared to other age groups, almost 2,500 episodes per 1,000 person-years. This compares to 1,200–1,300 epi-sodes in other age groups. Occurrence of intestinal worms was almost 10 times higher for children (338 per 1,000 person-years) compared to adults (33 per 1,000 person-years). Fever and skin problems were slightly more frequently reported for children under age six than adults, although small children and adults had about the same occurrence of eye problems (110 and 129 per 1,000 person-years for children and adults respectively). Pneumonia, although not as frequently reported as other conditions, primarily affected small children.

Malnutrition

The Z-scores of children’s nutritional status, compared to WHO standards in developing countries, are shown for height-for-age (Figure 6.2), weight-for-age (Figure 6.3) and weight-for-height (Figure 6.4). In all three fi gures, it is apparent that the children mea-sured in this study were found to be considerably below the WHO standards. The difference is most apparent in estimated calculations


Table 6.6: Rates of Reported Diseases per 1,000 Person-years (Recurrent Episodes Included)

Disease/Condition

Age Category

Under 6 6–11 12–17 Adult

Number 308 319 196 958Diarrhoea 2494 1279 1224 1253Fever 877 677 541 620Intestinal worms 338 238 143 33Skin problems 318 245 204 140Eyep 110 63 41 129Pneumonia 71 0 0 6Jaundice 13 0 0 8Typhoid 6 13 10 29Malaria 6 6 0 2Kalazar 0 6 0 2Others 52 113 143 424

Figure 6.2: Z-score Distributions of Height-for-Age in Children Aged 12 and below Compared to Standardised Data of WHO

of height- and weight- for-age, although weight-for-height remained below the WHO scores. Based on classifi cation of Z-scores into descriptive categories, it is estimated that most of the children in the study were malnourished, stunted or developmentally delayed, when compared to WHO standards (Figure 6.4). About 79 per cent of these children were found to be malnourished at (mild, moderate or severe level, 72 per cent stunted and 62 per cent were developmentally delayed based on head circumference. A substantial percentage was


Figure 6.3: Z-score Distributions of Weight-for-Age in Children Aged 12 and below Compared to Standardised Data of WHO

Figure 6.4: Z-score Distributions of Weight-for-Height in Children aged 12 and below Compared to Standardized Data of WHO

estimated to be at the extreme levels of nutritional defi ciency with 27 per cent severely malnourished, 22 per cent severely stunted, and eight per cent with severe developmental disabilities (Figure 6.5). It should be noted that the statistics generated by this study are sub-stantially higher than those reported by the Government of Nepal for 2006 as national average—49 per cent of underweight and 46 per cent of stunted children (Table 6.2).


CONCLUSION

The data collected in this health evaluation survey of lower caste rural families in Nepal was done to provide baseline statistics for evaluation of changes expected to occur following their access to clean water, sanitation and education. This information on mortality, morbidity and nutritional status of children provided insight into the health and well-being of a specifi c segment of the population. Although the mor-tality rate was much higher among older adults than among children, most morbid conditions occurred far more frequently among young children. This suggests that Nepal truly is undergoing a ‘health tran-sition’ phase, where its residents live for longer years. However, the fact that diarrhoeal-illnesses were twice as high in children under six compared to others, and that intestinal worms were four to 10 times more among the former reiterates the vulnerability of children to infectious diseases. Many of the health conditions, especially diarrhoea, intestinal worms, skin and eye infections, can be prevented through access to clean water and healthy sanitation practices.

Prior to the surveyed communities’ involvement with the clean water project, their sources of water were the shallow wells provided by the government. While the levels of illnesses and malnutri-tion were high in the study, we believe that the situation must be even more critical in areas where ponds and streams are utilised as

Figure 6.5: Percentage of Children Malnourished, Stunted, or at Risk for Developmental Problems Due to Lack of Nutrition in Two Communities of Rural Nepal


water sources. The high level of pathogens in the water supply has been well documented and the use of rivers for washing and illegal dumping of solid wastes on river banks has created a serious public health hazard in Nepal (Pokhrel and Viragraghavan 2005). In 2006, a household survey conducted in the Terai region found that over 61 per cent of the household water sources were contaminated with total coliforms (Atreya et al. 2006). While it was not possible to test faecal samples for the study, an earlier work has documented the presence of Eschericia coli, Vibria cholerae, Shigella, Rotavius A, Giardia intesinalis and Cryptospridium parvun in the Kathmandu valley and causes con-tamination in drinking water (Ono et al. 2001). Earlier research has estimated an annual mortality of 30,000 and 3.3 episodes per child due to Diarrhoea (Karn and Harada 2001).

The threat of waterborne diseases comes not only from surface water sources, such as rivers and ponds, but also from shallow groundwater sources accessed through hand-dug wells in Mujeliya and Rajaul villages. The elevated phosphate and nitrate levels in many water sources indicate contamination of surface water from agricultural areas and human settlements (Merz et al. 2004). These shallow wells, often at depths of less than 10 metres, are particularly susceptible to waterborne diseases because of the poor construction of wells into these shallow aquifers. Poor well construction often means there is little protection at the wellhead, with the well itself serving as a pathway for contaminants into the shallow aquifer. In addition, wells established in the shallow aquifers of this region present the added public health threat of arsenic contamination, mainly geogenic, due to the dissolu-tion of the arsenic-bearing minerals (Maharjan et al. 2007, Pokhrel et al. 2009, Yoshida et al. 2004, Zierold et al. 2004).

While acknowledging that some amount of contamination in water may appear natural, much of the contamination and its increasing levels in Nepal are the result of industrial growth, urbanisation and the general decrease of sanitary conditions associated with population growth (Pandey 2006). The primary sources of water pollution are related to sewage and other waste, industrial effl uents, agricultural discharges and industrial wastes from chemical industries, fossil fuel plants and nuclear power plants (Pandey 2006). These trends in


Nepal and other south and south-east Asian countries are expected to continue due to increased urbanisation (Pokhrel and Viragraghavan 2004).

A number of other factors that we were not able to capture in our study are known to infl uence health and nutritional status of people. For example, presence of Anaemia and iron defi ciency among young children in Nepal, especially those belonging to the lower castes, is due to their limited access to iron-rich food (Siegel et al. 2006). Other important factors, including socioeconomic status and educa-tion (Joshi et al. 2005), health infrastructure (Hotchkiss et al. 2002), and the workloads required of individuals (Yamanaka and Ashworth 2002), have also been documented as primary infl uences on the overall health and nutritional status of children in Nepal.

Levels of malnutrition obtained by us appear to be higher than those reported by others (Pandey et al. 2005; Shakya et al. 2004). However, the children in this study were almost all of the lowest castes and living in desperate poverty. This may account for the differences between results obtained by us and those studies which sampled a mix of castes. Most importantly, nutritional status is dependent upon the type and amount of food that a child eats—another variable of extreme importance but not under the purview of this study (Pradhan 2005). The need to integrate gender into water projects (Regmi and Fawcett 1999) and to upgrade health as a basic human right (Singh et al. 2006) have been identifi ed as a critical issue in Nepal. In the villages described by our case study, a local NGO programme is cur-rently underway to increase not only access to water and sanitation but to provide a comprehensive approach to improving health and economic conditions. Initiated by LEI (Living Earth Institute 2009) working in conjunction with WDSC of Janakpur, its focus is on the development of water supply and sanitation projects using a holistic approach for sustainability. Efforts including income generation, training and micro-lending initiatives; literacy and health education classes and other programmes to address specifi c needs identifi ed by the community are necessary to address the many facets of poverty. It is this type of programme with principles of sustainability that should be considered to help reduce poverty and improve health.


In the next few years, Nepal is likely to initiate more programmes to improve the quality of life for its people. Along with sound policies and their implementation, it is equally important that longitudinal monitoring of health parameters be incorporated into plans so that changes can be documented and policy modifi ed as adaptive man-agement when necessary. Efforts and programmes implemented by both public and private sectors must be coordinated if improvements are to occur. However, given the current unstable political situation, essential infrastructure for sanitation and water will remain inadequate for the foreseeable future. Real improvements in the health of the Nepali people will continue to be a considerable challenge for its public health leaders, but there is no more critical mission for these leaders in the near term.

REFERENCES

Atreya, K., S. Panthee, and P. Sharma. 2006. ‘Bacterial Contamination of Drinking Water and the Economic Burden of Illnesses for the Nepalese Households’, International Journal of Environmental Health Research, 16(5): 385–90.

CDC. 2005. EpiInfo (NUTSTAT module), Centers for Disease Control. Available online at http://www.cdc.gov/epiinfo/. Downloaded on 1 February 2007

GoN. 2003. Annual Report, Department of Health Services, 2058–59 (2001–02). Kathmandu: His Majesty’s Government of Nepal, Ministry of Health. As the political scenario has changed, do we need to change the way we refer the Nepali government? Or as these are old records, use the title given in them?

———. 2004. Annual Report, Department of Health Services 2059–60 (2002–03). Kathmandu: His Majesty’s Government of Nepal, Ministry of Health.

———. 2005. An Assessment of the Implementation of the Tenth Plan (PRSP): Second Progress Report on the Road to Freedom from Poverty. National Plan-ning Commission, Kathmandu: Singh Durbar.

———. 2007a. Three-Year Interim Plan: An Approach Paper (2064/65–2066/67). National Planning Commission, Kathmandu: His Majesty’s Government of Nepal.

———. 2007b. Millennium Development Goals in Nepal: Progress on Key Indicators. National Planning Commission. Kathmandu: His Majesty’s Government of Nepal.

———. 2008. ‘National Urban Water Supply and Sanitation Sector Policy’, Ministry of Physical Planning and Works. Kathmandu: His Majesty’s Govern-ment of Nepal.


Hotchkiss, D.R., N.B. Mock, and E.E. Seiber. 2002. ‘The Effect of the Health Care Supply Environment on Children’s Nutritional Status in Rural Nepal’, Journal of Biosocial Science, 34(2): 173–192.

Joshi, N., T. Rikimaru, S. Pandey. 2005. ‘Effects of Economic Status and Education Level on the Height and Weight of Community Adolescents in Nepal’, Journal of Nutritional Science and Vitaminology, 51(4): 231–38.

Karn, S.K. and H. Harada. 2001. ‘Surface Water Pollution in Three Urban Territories of Nepal, India and Bangladesh’, Environmental Management, 28(4): 483–96.

Living Earth Institute. 2009. Seattle, WA. Available online at http://www.living-earth.org/. Downloaded on 23 December 2009.

Maharjan, M., C. Watanabe, S. Akhtar, M. Umezaki, R. Ohtsuka. 2007. ‘Mutual Interaction between Nutritional Status and Chronic Arsenic Toxicity Due to Groundwater Contamination in the area of Terai, Lowland Nepal’, Journal of Epidemiology and Community Health 61(5): 389–94.

Merz, J., G. Nakarmi, S. Shrestha, B.M. Dahal, B.S. Dongol, M. Schaffner, S. Shakya, S. Sharma, and R. Weingartner. 2004. ‘Public Water Sources in Rural Water-sheds of Nepal’s Middle Mountains: Issues and Constraints’, Environmental Management 34(1): 26–37.

Ono, K., S.K. Rai, M. Chikahira, T. Fujimoto, H. Shibata, Y. Wada, H. Tsuji, Y. Oda, G. Rai, C.D. Shrestha, K. Masuda, H.G. Shrestha, T. Matsumura, H. Hotta, T. Kawamura, and S. Uga. 2001. ‘Seasonal Distribution of Enteropathogens Detected from Diarrheal Stools and Water Samples Collected in Kathmandu, Nepal. The Southeast Asian Journal of Tropical Medicine and Public Health, 32(3): 520–26.

Pandey, S. 2006. ‘Water Pollution and Health’, Kathmandu University Medical Journal (KUMJ), 4(1): 128–34.

Pandey, S., I. Dudani, A. Pradhan. 2005. ‘Health Profi le of School Children in Bhaktapur’, Kathmandu University Medical Journal (KUMJ), 3(3): 274–80.

Pokhrel, D., B.S. Bhandari, T. Viraraghavan. 2009. ‘Arsenic Contamination of Groundwater in the Terai Region of Nepal: An Overview of Health Concerns and Treatment Options’, Environment International, 35(1): 157–61.

Pokhrel, D. and T. Viraraghavan. 2004. ‘Diarrhoeal Diseases in Nepal vis-à-vis Water Supply and Sanitation’, Journal of Water and Health, 2(2): 71–81.

———. 2005. ‘Municipal Solid Waste Management in Nepal: Practices and Chal-lenges’, Waste Management 25(5): 555–62.

Pradhan, A. 2005. ‘Child Nutrition in Nepal’, Kathmandu University Medical Journal (KUMJ ), 3(1): 2–3.

Regmi, S.C. and B. Fawcett. 1999. ‘Integrating Gender Needs into Drinking-Water Projects in Nepal’, Gender and Development 7(3): 62–72.

Siegel, E.H., R.J. Stoltzfus, S.K. Khatry, S.K. LeClerq, J. Katz, J.M. Tielsch. 2006. ‘Epidemiology of Anemia in 4 to 17-Month Old Children Living in South Central Nepal’, European Journal of Clinical Nutrition 60(2): 228–35.


Shakya, S.R., S. Bhandary, P.K. Pokharel. 2004. ‘Nutritional Status and Morbidity Pattern among Governmental Primary School Children in the Eastern Nepal’, Kathmandu University Medical Journal (KUMJ ), 2(4): 307–14.

Singh, S., E. Bohler, K. Dahal, and E. Mills. 2006. ‘The State of Child Health and Human Rights in Nepal’, PLoS Medicine 3(7): e203.

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Yamanaka, M. and A. Ashworth. 2002. ‘Differential Workloads of Boys and Girls in Rural Nepal and Their Association with Growth’, American Journal of Human Biology, 14(3): 356–63.

Yoshida, T., H. Yamauchi, and G.F. Sum. 2004. ‘Chronic Health Effects in People Exposed to Arsenic via the Drinking Water: Dose–Response Relationship in Review’, Toxicology and Applied Pharmacology, 198(3): 243–52.

Zierold, K.M., L. Knobelock, and H. Anderson. 2004. ‘Prevalence of Chronic Diseases in Adults Exposed to Arsenic-Contaminated Drinking Water’, American Journal of Public Health 94(11): 1936–37.

7

Disease Burden Linked to Incomplete Water and Sanitation Coverage in Orissa, India

AIDAN A. CRONIN AND SRIHARI DUTTA1

INTRODUCTION

IMPROVEMENTS IN WATER supply, both in terms of quantity and quality, together with the associated provision of sanitation facilities can make signifi cant impacts on the incidence of diarrhoeal diseases and lead to a decline in child mortality rates (Blum and Feachem 1983; Cronin et al. 2006a,b). Globally, improving water, sanitation and hygiene sector has the potential to prevent at least 9.1 per cent of the disease burden in disability-adjusted life years (DALYs) or 6.3 per cent of all deaths (Prüss-Ustün et al. 2008). Green et al. (2009) estimate that reducing unmet rural sanitation needs by 65 per cent would reduce the world’s total morbidity by 41 million DALYS, equivalent of saving 1.2 million lives a year.

Indeed, the level of mortality linked to unclean water and poor sanitation is still not widely appreciated. Yet, globally, diarrhoea kills more people than tuberculosis or malaria and fi ve times as many chil-dren die of diarrhoea than of Acquired Immune Defi ciency Syndrome (AIDS) (UNDP 2006,). A staggering 25 per cent of child mortality (under 14 years) annually is related to water, sanitation and hygiene (WASH) diseases, while for all age groups WASH-related diseases make up 6 per cent of total mortality (Fewtrell et al. 2007). The total global morbidity estimate of WASH diseases comes to 117 million

1 The authors wish to thank several colleagues such as D. Johnston and S. Chowdhury, UNICEF, Delhi, and P. Bharati, SWSM Orissa, who provided com-ments to strengthen this paper.

The views expressed herein are those of the authors and do not necessarily refl ect the views of UNICEF or the United Nations.

138 Aidan A. Cronin and Srihari Dutta

DALYs for children under 14 years, 22 per cent of the overall fi gure. For all age groups, the global morbidity estimate for WASH diseases is 135 million DALYs, 9 per cent of the total.

Other estimates suggest that poor sanitation may be the single greatest contributing factor to the 9.7 million child deaths that occur each year (Water Aid 2008). Kaler (2008) estimates that 1.8 million children die each year from diarrhoeal illness but that less than 1,000 of these deaths occur in the developed world. It is obvious that WASH service defi ciencies hit children the hardest and clearly underlines a need for increased and sustained efforts in documenting the real impact on human health (above all children) caused by incomplete or substandard WASH services.

Despite rapid economic growth and massive increase in expenditure on water and sanitation, India still lags behind in improved coverage and has enormous morbidity and mortality due to water-borne dis-eases. Though the percentage of population practising open defecation in southern Asia has declined from 65 per cent to 48 per cent in the period 1990–2006, 55 per cent of the 1.2 billion people in the world practising open defecation are in India (WHO/UNICEF, 2008). Over 200 million people in southern Asia do not have access to improved drinking water sources while 67 per cent of Indians do not use no drinking water treatment practice (WHO/UNICEF 2008). Fewtrell et al. (2007) have estimated the national burden of disease associ-ated with poor water, sanitation and hygiene (Tables 7.1, 7.2). Diarrhoea kills nearly half a million Indians a year and India loses almost 26 million DALYs per year due to poor water and sanitation. This is equivalent to each and every Indian losing 9 healthy days every year only due to water and sanitation. It is also obvious, as shown in Tables 7.1 and 7.2, that diarrhoea and malaria represent the majority of the burden of disease associated with incomplete water and sanita-tion coverage.

Orissa, located in the eastern coastal area of India ( Map 7.1) makes up 2.1 per cent of the land area of India and has a population of almost 40 million, or 3.5 per cent of the Indian total. Some of the key details on Orissa are give in Table 7.3. The population of Orissa would be comparable to that of Spain but Orissa has only 30 per cent of land area of Spain. It is among the poorest and least developed states in the country (India Today 2008).

Disease Burden 139

The percentage of population living below poverty line in Orissa declined from 65.29 per cent in 1983–84 to 39–9 per cent in 2004–05. The corresponding Indian national values declined from 44.48 per cent to 21.8 per cent over the same period (GoO 2006–07). Orissa’s average per capita income of ` 16,306 in 2004–05, was still only 68 per cent of the national average (GoI 2009). In fact, this sum is only fractionally above one US Dollar per day, one of the many defi n-ing indicators of poverty. Hence, while improvements occur, Orissa is still substantially below the Indian average. In addition, despite improvements between the National Family Health Survey (NFHS)-2, in 1998–99 and NFHS-3 in 2005–06, 40 per cent of children in Orissa are underweight and 44 per cent stunted.

Orissa has improved the health of its people since 1990. Crude death rate (CDR) declined from 13.1 to 9.2 per 1,000 population (SRS 2008); crude birth rate (CBR) has declined from 33.1 to 21.5 per 1,000 population (SRS 2008). Infant mortality rate (IMR) is still in excess of Indian national values though the gap has recently reduced (Figure 7.1). Neonatal mortality rates are very high at 61.6 per cent of the infant mortality, mostly due to infection and low-birth weight and often are linked with the overall sanitation situation (SRS 2006). Under-5 child mortality rates have also dropped signifi cantly from a state average of 231 in 1976 to 121 in 1998–2002 (SRS 2008) and to 91 per 1000 in NFHS-3.

Table 7.1: Extent of Mortality Associated with Poor Water and Sanitation Provision in India in 2002

Total deaths 10,378,500All water and sanitation-related deaths 597,500 (6% of total)Deaths due to Diarrhoea 456,400 (76% of WASH deaths)Deaths due to Malaria 9,400 (2% of WASH deaths)Source: Fewtrell et al. (2007).

Table 7.2: Extent of Morbidity Associated with Poor Water and Sanitation Provision in India in 2002

Totals DALYS 299,910,000All water and sanitation-related DALYs 25,888,000 (9% of total)DALYS due to Diarrhoea 15,254,000 (59% of all WASH DALYs)DALYS due to Malaria 844,000 (3% of all WASH DALYs)Source: Fewtrell et al. (2007).

140 Aidan A. Cronin and Srihari DuttaM

ap 7

.1:

Loca

tion

of O

riss

a St

ate

in th

e Ea

st o

f Ind

ia (

inse

t) a

nd D

emar

cati

on o

f the

30

Dis

tric

ts in

the

Stat

e

Disease Burden 141

Table 7.3: Key Statistics on Orissa: Population Figures from Census of India (2001)

Area (sq. km) 155,707Population 36.8 million% Rural population 85%% Scheduled Caste 16.5%% Scheduled Tribe 22%Number of districts 30Numberof blocks 314Numberof GPs 6,234NNumberof Villages 51,439

Figure 7.1: Infant Mortality Rates during 1990–2007 for India and Orissa

Source: SRS (2008).

However, despite the improvements in health terms, water-borne disease outbreaks are still an annual occurrence in many districts of Orissa. The percentage of rural habitations in Orissa with access to improved drinking water sources (that is habitations defi ned as fully or partially covered though fi gures for access to improved drinking water source may be smaller than this) is in excess of 80 per cent. The equivalent national value for India is 70 per cent in April 2008. Seven per cent of a total of 139,338 habitations in Orissa have been identifi ed to date as being affected by some type of chemical contami-nation (RWSS 2008). As regards microbiological water quality, 400 samples were analysed for Thermo-Tolerant Coliforms (TTC) and Faecal streptococci (FS) as part of a pilot study across all blocks in


Koraput district, in 2007. Simultaneously, sanitary surveys for each water point were conducted. Interestingly, 4.5 per cent of samples had TTC values in excess of 10 per cent, while 31 per cent had FS values of 10 per cent (Cronin et al. 2008). Strong correlation between risk assessed and microbial water quality was found, thereby indicating the usefulness of a risk-based approach.

Government of India’s total sanitation campaign (TSC) aims to end open defecation in the country at the earliest opportunity. Rural sanitation in Orissa has improved signifi cantly since 2001 when only 8 per cent of rural households had latrines. Today rural sanitation coverage still stands at 30 per cent of the TSC target, as of May 2009 (as per the fi gures provided on the website of the Ministry of Rural Development [MoRD] at http://www.ddws.nic.in/), compared to the Indian average of 45 per cent. Research evidence from Orissa shows that the increase in latrine ownership may have reduced child Diarrhoea by as much as 30 per cent (World Bank 2008).

In order to quantify improvements required in water and sanita-tion service, a comprehensive quantifi cation of the current burden of disease is required and this can be calculated as per the WHO methodology given in Fewtrell et al. (2007). A total of 11 diseases or injuries are listed in this approach and estimates made for each national population for the data available from 2002. Our study focused on the two most critical water-related disease burdens, severe diarrhoea and malaria. These constitute the vast majority of diseases connected with poor water and sanitation provision in the state; Tables 7.1 and 7.2 clearly show that diarrhoea and malaria make up for 78 per cent of all water- and sanitation-related mortality and 62 per cent of all water- and sanitation-related morbidity in India.

METHODOLOGY

Several information sources were used to compile the required data. The primary sources were the Department of Drinking Water Supply, Ministry of Rural Development, Government of India (MoRD 2008). The sanitation statistics were available as the percent-age of the total sanitation campaign achieved for rural households to which the baseline fi gure of 8 per cent coverage in Orissa in 2001 has

Disease Burden 143

been added. Figures for water coverage are given as percentage of rural habitations fully covered; the number of fully covered habitations has increased from 63 per cent in 2003 to 71 per cent in 2007.

Mortality health data were collected from the Sample Registration System (SRS) of the Government of India (SRS 2008). Incidences of disease and mortality due to disease information were collected from Orissa Multi-Disease Surveillance System (OMDSS) and the Integrated Disease Surveillance Project (IDSP) for Diarrhoea and Malaria from the National Vector-borne Disease Control Programme (NVBDCP), Orissa Offi ce.

A scenario-based approach is used to estimate the disease burden of Diarrhoeal illness related to unsafe WASH provision. Exposure catego-ries must be defi ned to do this and these are based on typical levels of access to water and sanitation, the load of faecal-oral pathogens in the environment (based on qualitative assessment of sources and disease circulation in the community) along with related risk factors.

Three categories of people are present in Orissa, those with improved water supply and basic coverage, those with neither and those with one of the two. The best estimate for relative risk for these scenarios is 6.9, 11.0 and 8.7 respectively. Proportions of the populations in each category can be estimated using the district water and sanitation coverage fi gures. The methodology then allows the estimation of the Attributable Fraction (AF) of diarrhoea related to water and sanitation to be calculated using the equation AF = (Σpi.RRi – 1)/Σpi.RRi where:

pi = the proportion of the population at exposure category ‘i’; Σ pi = 1

RRi = the relative risk at exposure category ‘i’, compared to the ideal level (with RR = 1).

In situations where less than 98 per cent of the population have access to basic sanitation, the AF ranges between 86 and 91 per cent with sanitation having a greater impact on the AF than water coverage.

Experts have estimated attributable fractions for six regions of the world for Malaria though these are only regional averages. Local variations can prove to be considerable, and the regional estimates cannot, therefore, substitute national nor even sub-regional studies.


However, due to lack of more detailed localised information, a mean AF of 42 per cent was taken for the South and East Asia region (Fewtrell et al. 2007, Table 8) refl ecting the best estimate of the proportion of Malaria morbidity and mortality related to inadequate water and sanitation services.

The upper and lower 95 per cent confi dence intervals are 30 and 54 per cent, respectively.

DALY values, associated with Diarrhoea only, were calculated for Orissa using the available population, water and sanitation coverage and health data from 2002. This was carried out using the method of Murray and Lopez (1996), and Fishman et al. (2004). Population data was derived from the 2001 Indian census data (GoI 2001).

RESULTS Tables 7.4 and 7.5 present the cumulative fi gures for both cases and deaths of malaria and severe diarrhoea during 2002 to 2007 and the related numbers of both cases and deaths linked to poor water and sanitation.

Overall severe diarrhoea linked to poor water and sanitation has reduced from over 140,000 cases in 2002 to 107,000 in 2007. Malaria cases linked to poor water and sanitation has been reduced from 175,000 to 153,500 in 2007. Severe Diarrhoea and Malaria case rates per population for the period 2002–07 and 2004–07 respectively are given in Map 7.2. Annual average values range between 10.2 severe Diarrhoea cases per 1,000 persons for Jharsuguda district to 1.1 for Cuttack district. Annual average values for Malaria range between 47.8 cases per 1,000 persons for Kandhamal district to 0.1 for Puri district. It is clear from the data presented in columns one and two of Tables 7.4 and 7.5 that the majority of the burden of disease associ-ated with severe Diarrhoea and Malaria in Orissa is attributable to poor water and sanitation provision.

The district level comparison between 2002 and 2006 diarrhoea cases are given in Figure 7.2. The results of estimates of DALYs linked to Diarrhoea and national values are presented in Table 7.6. Orissa suffers in the region of 637,000 DALYs per year solely linked to diar-rhoea, that is 3.5 per cent of the total Indian population shouldering 4.2 per cent of the Diarrhoea DALYs burden.

Disease Burden 145

Tab

le 7

.4:

Tot

al D

iarr

hoea

Cas

es a

nd D

eath

s (2

002–

07)

wit

h th

e A

ttri

buta

ble

Esti

mat

e D

ue to

Poo

r W

ater

and

San

itat

ion

Pro

visi

on

Year

Seve

re D

iarr

hoea

Cas

esAt

trib

utab

le to

Poo

r W

ater

and

San

itatio

nSe

vere

Dia

rrho

ea D

eath

sC

ase f

atal

ity R

ate %

Attr

ibut

able

to P

oor

Wat

er a

nd S

anita

tion

2002

156,

872

140,

318

453

0.29

405

2003

144,

673

129,

174

513

0.35

458

2004

116,

750

104,

026

285

0.24

254

2005

134,

275

119,

373

259

0.19

230

2006

103,

531

91,8

6093

0.09

82

2007

120,

939

107,

080

389

0.32

344

Sour

ce:

OM

DSS

/ID

SP.


Tab

le 7

.5:

Tot

al M

alar

ia C

ases

and

Dea

ths

(200

4–07

) w

ith

the

Att

ribu

tabl

e Es

tim

ate

due

to P

oor

Wat

er a

nd S

anit

atio

n P

rovi

sion

Year

Mal

aria

Cas

esAt

trib

utab

le to

Poo

r Wat

er

and

Sani

tatio

nM

alar

ia D

eath

sC

ase F

atal

ity R

ate %

Attr

ibut

able

to P

oor W

ater

an

d Sa

nita

tion

2004

416,

771

175,

044

(125

,031

, 225

,056

)28

30.

0711

9 (8

4, 1

52)

2005

396,

573

166,

561

(118

,971

, 214

,149

)25

50.

0610

7(3

2,58

)

2006

372,

710

1565

38(1

11,8

13 2

0126

3)26

00.

0710

9(3

2, 5

9)

2007

365,

593

153,

549

(109

,677

, 19

7,42

0)–

––

Sour

ce:

NV

BD

CP.

Not

e: 95

per

cen

t con

fi den

ce in

terv

al v

alue

s giv

en in

par

enth

esis.

Disease Burden 147M

ap 7

.2:

Wat

er, S

anit

atio

n, D

iarr

hoea

and

Mal

aria

Ind

icat

ors

in O

riss

a

Sour

ces:

MoR

D, O

MD

SS/I

DSP

, NV

BD

CP.

Not

e: C

ompa

rison

of

the

30 d

istric

ts o

f O

rissa

in

term

s of

wat

er p

erce

ntag

e co

vera

ge (

2007

), sa

nita

tion

perc

enta

ge c

over

age

(200

7),

seve

re d

iarr

hoea

(ave

rage

num

ber o

f cas

es p

er 1

000

pers

ons d

urin

g 20

02–0

7) a

nd m

alar

ia p

reva

lenc

e (a

vera

ge n

umbe

r of c

ases

per

10

00 p

erso

ns d

urin

g 20

04–0

7). T

he k

ey is

show

n in

the

fi gur

e (in

ord

er o

f wat

er, s

anita

tion,

dia

rrho

ea, m

alar

ia) a

nd th

e ca

tego

ries

of p

rovi

sion

are

as p

er t

he a

ssoc

iate

d ta

ble

whi

ch g

ives

1 r

epre

sent

ing

the

wor

st i

ndic

ator

s in

the

Sat

e an

d 3

the

best

ran

ge o

f in

dica

tors

.


Figure 7.2: Evolution of Severe Diarrhoea Cases in Orissa Districts 2002–06

Table 7.6: Diarrhoea DALYs in India and Orissa, 2002

Item India Orissa

Population 1,049,550,000 36,804,660Total Diarrhoea cases – 156,872Diarrhoea cases per 1,000 persons per year – 4.3Total Diarrhoea deaths per year 456,400 453Diarrhoea deaths per 1,000 persons per year 0.435 0.0123Total Diarrhoea DALYs per year 15,254,000 637,000Diarrhoea DALYs per 1,000 persons per year 14.53 17.31

Source: Fetwrell et al. (2007) and author.

Cross-plots of health and environmental data present interesting correlations; the malaria Annual Parasite Index (API) can was plotted against sanitation coverage (Figure 7.3).

ANALYSIS

Table 7.4 shows that severe Diarrhoea cases have decreased every year between 2002 and 2006 to an overall 50 per cent though there was an increase again in 2007 by 20 per cent from 2006. Figure 7.2 shows that in only six districts has Diarrhoea increased during 2002–06. Malaria cases have steadily reduced from 2002 to 2004 though the number of deaths per year remains approximately the same. Case Fatality Rates (CFR) for Malaria and severe Diarrhoea remain more or less

Disease Burden 149

Figure 7.3: Annual Parasite Index (API) During 2004 to 2007 Versus Sanitation Coverage (%) in the 30 Districts of Orissa in 2007

Source: OMDSS/IDSP.


unchanged during the period 2002 and 2006. The reduction in cases, but not in CFR, may refl ect increased impact and success in the prevention of disease by behavioural change communication means. This may also refl ect why the Diarrhoea-associated deaths as shown in Table 7.6, are much lower in Orissa (0.0123) than the whole of India (0.435). An alternative explanation may be that not all deaths relating to severe Diarrhoea are being fully captured.

Table 7.6 shows Orissa’s Diarrhoea burden is almost 20 per cent above the national average. According to WHO, 33 DALYs corres-pond to the death of an infant and 36 Diarrhoeal DALYs correspond to the death of a person aged between 5–20 (Mathers et al. 2004). Hence, Orissa’s diarrhoeal burden is the equivalent of 19,300 infant deaths. Map 2 shows that when three bands of service indicators are chosen for the water and sanitation service delivery and the burden of disease (1 = worst, 3 = best ranking) then 19 districts in 2007 had number 3 rating for WASH provision and 7 districts (6 in southern Orissa) had number 3 in disease indicator terms.

Figure 7.3 further emphasises the links between environmental health and water and sanitation and shows how a proxy indicator for Malaria, API, is strongly linked to sanitation coverage in the districts. Of course, with many other inter-related and compounding factors affecting these variables including poverty, access to health care, remoteness of settlements, nutrition status, and so on it is simplistic to say sanitation coverage alone can reduce Malaria prevalence. Other measures including decreased parasite numbers via environmental reduction measures and primary prevention barriers are to be strength-ened and wider malaria education measures are needed in conjunction with improved water and sanitation provision.

LIMITATIONS

There are several limitations to this analysis. Water and sanitation coverage updates are at district level and so in-district variance is not refl ected and, therefore, can result in some approximation in the cal-culation of the AF values. The water and sanitation coverage values used are the offi cial fi gures available though in reality both coverage fi gures on the ground will be lower due to non-use or non-functioning

Disease Burden 151

nature of some of the water and/or sanitation schemes. In some cases, water scheme fi gures may refl ect on fund disbursement rather than scheme completion.

Besides, AF values themselves are best estimates as per the WHO methodology. An upper and lower bound estimate of Diarrhoea AF can be calculated with the methodology. The percentage difference between upper and lower bounds and the best estimate were calculated for 50 water and sanitation combinations and shows that calculated AFs can, on average, deviated in the order of approximately ±10 per cent. In addition, health statistic data are also provided at the district level and thus does not refl ect in-district variations. Also, AFs estimates themselves, especially for Malaria, have employed regional estimates (Prüss-Ustün et al. 2008) though there may well be wide local varia-tions; more detailed local study information must be collected in order to improve future AF estimates, which would provide an improved estimation of the situation.

Health centre statistics only refl ect those who present themselves for assistance, that is passive surveillance. Active case fi nding was not undertaken, and, therefore, the fi gures presented in Tables 7.4 and 7.5 do not fully capture the extent of the burden of these diseases. Independent case collaboration of patients that present themselves at health clinics was missing and quality control and monitoring was limited, given the diffi cult working conditions and high workload placed on medical practitioners. As this study deals with large popu-lations it is thus more of a situational review rather than a controlled scientifi c study that can quantify the infl uences of variables. Such inde-pendent collaboration of morbidity and mortality would greatly help to improve the estimates of water and sanitation disease burdens.

The other diseases listed in the WHO methodology such as intestinal nematode infections, malnutrition-related WASH illness, schistosomiasis, trachoma, lymphatic fi lariasis, onchocerciasis, dengue, Japanese encephalitis and drowning, were not considered due to lack of occurrence in the districts or more importantly, the unavailability of data for these diseases. The malnutrition-related WASH illness would be especially important given the poor nutrition status of large sections of the population in Orissa. The poor performance of Orissa in nutritional indicators is apparent when it is noted that the state


ranked 5th on the Nutrition Index in 1994 (Wiesmann 2004); but now ranks 12th on the India State Hunger Index, 2008 (ISHI 2008). It is intended to estimate this burden of malnutrition-related disease linked to WASH in the near future.

The WHO methodology, principally targeted at national popula-tions, was applied at the regional level. Nonetheless, given the fact that the population of Orissa is equivalent or more than many countries in their own right, the use of this methodology is very appropriate at this scale. The methodology acknowledges that there are signifi cant sources of uncertainty in the calculation of exposure risks and in data compilation; this also holds true for this study. There are also limitations in the defi nitions of improved and unimproved water and sanitation services; these often consider only the hardware aspects and may not take into account water quality or temporal variations in service issues.

Care must be taken to ensure that the broad categories of supply do not fail to encompass discrimination in populations and vulner-ability groups who may offi cially have access to improved services but not fully and so depend on higher risk strategies. For example safe water sources are not maintained or functioning and so unprotected water bodies become the alternative or non-use of toilets so that open defecation becomes the norm.

It is worth noting that the sensitivity of DALY calculations to crude mortality rates is signifi cant though it is not always easy to get the most accurate crude mortality rates. In addition, care must be taken with output indicators, such as DALY calculations, as they can prove diffi cult to understand at the fi eld level, as they cannot be easily compared with crude mortality rates or number of consultations.

It is, of course, obvious to state that malaria case reduction is linked not only to improving water and sanitation but also to other measures including vector control such as anti-adult measures such as residual spray, space application and individual protection, and anti-larval measures such as larvicidal, source reduction and integrated control. Improved sanitation and drainage, of course, aid source reduction by better controlling the environment and reducing stagnant water volumes for mosquitoes to breed in.

Disease Burden 153

FINDINGS AND LEARNINGS

These estimates can aid resource managers, for example administra-tors managing public funds, to better understand the link between incomplete water and sanitation coverage and disease. It can thus assist in the prioritisation of interventions, both in terms of technical options and geographical areas. The largest burdens of disease and the populations shouldering them should benefi t fi rst from additional expertise or resources for water and sanitation interventions. Provid-ing such a clear criteria for decision-making could also help in aiding transparency, target the most needy and provide the most substantial economic payback per investment.

These results also highlight the need for increased links between water, sanitation and health sectors. The link between health and sanitation has traditionally been very weak in many countries. As quoted in the editorial of the leading medical journal The Lancet in March 2008

The shamefully weak presence of the health sector in advocating for improved access to water and sanitation is incomprehensible and completely short-sighted …the global health community is standing aside, absolving itself of responsibility, and fi rmly passing the buck to the water and sanitation sectors (The Lancet 2008).

This is all the more important given that development assistance for health increased to 15 per cent by 2004; in contrast, aid to water and sanitation has fallen as a share of overall development assistance from 8 per cent to 5 per cent (UNDP 2006).

Such increased collaboration across sectors is also required to ensure optimal value for money. According to WHO estimates (Hutton and Bartram 2008), to achieve the basic target of halving the population that goes without sustainable access to water supply by 2015, developing countries would need to spend US $ 42 billion on new coverage while the cost of maintaining existing water sup-ply services is estimated to total an additional US $ 322 billion. An estimated US $ 9.5 billion is required annually to meet the sanitation Millennium Development Goals by 2015 (Hutton and Haller 2004).


Such interventions as improved hygiene are especially important for public health and water and sanitation collaboration, indeed without such convergence in hygiene the full public health benefi ts of improved water and sanitation will not be realised.

Further, work is needed on many fronts. More fi eld-based trials of the WHO methodology would help reduce the many uncertainties and strengthen the approach for the future. Many inputs, such as malaria AF estimation, need local studies to give a more accurate localised picture over regional estimates. Stronger epidemiological links are also required for WASH professionals so as to present these arguments to resource managers and, therefore, related economic arguments could help further strengthen and consolidate the arguments.

CONCLUSION

The estimate fi ndings in this chapter, based on the WHO methodol-ogy of Fewtrell et al. (2007), demonstrate an unacceptably large burden of disease associated with poor water and sanitation in Orissa, and a comparison with average Indian national values shows that Orissa diarrhoeal estimates are higher. Orissa suffers in the region of 637,000 DALYs per year, solely linked to diarrhoea, that is 3.5 per cent of the total Indian population is shouldering 4.2 per cent of the national Diarrhoea DALYs burden. Diarrhoea DALYs per capita in Orissa are 19 per cent higher than the Indian average.

These estimates of disease burden underlines signifi cant suffering and associated social burden among the population, attributable to incomplete water and sanitation provision. These estimates can aid resource managers to better understand the link between incomplete water and sanitation coverage and disease. It can also help them to compare among the various technical options and administrative areas and identify those requiring additional expertise or resources specifi c to water and sanitation in order to reduce unacceptably large related burdens of disease. Additionally, the results merit the need for increased dialogue and collaboration across water and sanitation and health sectors on how to ensure maximum impact of water and sanitation interventions.

Disease Burden 155

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Cronin, A.A., J. Rueedi, E. Joyce, S. Pedley. 2006a. ‘Monitoring and Managing the Extent of Microbiological Pollution in Urban Groundwater Systems in Developed and Developing Countries’, in J.H. Tellam, M.O. Rivett, and R.G. Israfi lov (eds), Urban Groundwater Management and Sustainability’, NATO Advanced Study, Institute Earth and Environmental Sciences, Vol. 74, 299–314, Dordrecht, Holland: Springer Publishers.

Cronin, A.A., N. Breslin, J. Gibson, S. Pedley. 2006b. ‘Monitoring Source and Domestic Water Quality in Parallel with Sanitary Risk Identifi cation in Northern Mozambique to Prioritise Protection Interventions’, Journal of Water and Health, 4(2): 333–45.

Cronin, A.A., R.P. Misra, P. Srivastava. 2008. ‘Drafting Water Quality Guidelines for Orissa State, India’, in P. Sinha and S. Rana (eds), Proceedings of the 2nd World Aqua Congress, ‘Global Climate Change and Water Resources: Current Practices and Planning for the Future’, pp. 321–28.

Fewtrell, L., A. Prüss-Üstün, R. Bos, F. Gore, J. Bartram. 2007. Water, Sanitation and Hygiene: Quantifying the Health Impact at National and Local Levels in Countries with Incomplete Water Supply and Sanitation Coverage. Environmental Burden of Disease, Series No. 15, Geneva: World Health Organization, 71 pp.

Fishman, S.M., L.E. Caulfi eld, M. de Onis, Blössner, A.A. Hyder, and L. Mullany. 2004. ‘Childhood and Maternal Underweight’, in M. Ezzati, A. Lopez, A. Rodg-ers, and C.J.L. Murray (eds), Comparative Quantifi cation of Health Risks: Global and Regional Burden of Disease due to Selected Major Risk Factors, pp. 39–162. Geneva: World Health Organization.

GoI. 2001. Census of India, Government of India. Available online at http://www.censusindia.net/. Downloaded in May 2009.

———. 2009. Union Budget, Government of India. Available online at http://indi-abudget.nic.in. Downloaded in May 2009.

GoO. 2007. Economic Survey 2006–07. Department of Planning and Coordination, Government of Orissa.

Green, S.T., M.J. Small, and E.A. Casman. 2009. ‘Determinants of National Diarrheal Disease Burden’, Environmental Science and Technology, 43(4): 993–99.

Hutton, L. and J. Bartram, 2008. ‘Attaining the Water and Sanitation Target’, Bulletin of the World Health Organization, 86(1): 19.

Hutton, G. and L. Haller. 2004. Evaluation of the Costs and Benefi ts of Water and Sanitation Improvements at the Global Level. Geneva: World Health Organization.

India Today. 2008. ‘State of the States: The Defi nitive Ranking of the Quality of Life across India’, 33(38) (22 September).


ISHI. 2008. ‘India State Hunger Index: Comparison of Hunger across States’. Available onlie at http://www.ifpri.org/pubs/cp/ishi08.pdf. Downloaded in May 2009.

Kaler, S.G. 2008. ‘Diseases of Poverty with High Mortality in Infants and Children: Malaria, Measles, Lower Respiratory Infections and Diarrheal Illnesses’, Annals of the New York Academy of Science, 1136, 28–31.

Lancet, The. 2008. ‘Keeping Sanitation in the International Spotlight’, Editorial, 371(9618): 1045.

Mathers, C.D., C. Bernard, K.M. Ilburg, M. Inoue, D.M. Fat, K. Shibuya, C. Stein, N. Tomijima, and H. Xu. 2004. ‘Global Burden of Disease in Data Sources, Methods and Results’, Global Programme on Evidence for Health Policy Dis-cussion Paper No. 54, World Health Organization, Geneva.

MoRD. 2009. ‘Total Sanitation Campaign On-line Monitoring’, Department of Drinking Water Supply, Ministry of Rural Development, Government of India. Available online at http://www.ddws.gov.in/. Downloaded in May 2009

Murray, C.J.L. and A.D. Lopez. 1996. The Global Burden of Disease, Cambridge, MA: Harvard School of Public Health, WHO, World Bank.

Prüss-Ustün A., R. Bos, F. Gore, J. Bartram. 2008. Safe Water, Better Health: Costs, Benefi ts and Sustainability of Interventions to Protect and Promote Health. Geneva: World Health Organization.

RWSS. 2008. Department of Rural Water Supply and Sanitation, Bhubaneswar, Orissa.

SRS. 2006. Sample Registration System Statistical Report. India Offi ce. New Delhi: Registrar General.

———. 2008. Sample Registration System Statistical Report. India Offi ce. New Delhi: Registrar General.

UNDP. 2006. Beyond Scarcity: Power, Poverty and the Global Water Crisis, Human Development Report 2006, New York: Palgrave Macmillan Publishers.

Water Aid. 2008. Tackling the Silent Killer: The Case for Sanitation, 18 pp. London: WaterAid.

WHO/UNICEF. 2008. Joint Monitoring Programme for Water Supply and Sanita-tion, Geneva: World Health Organization / United Nations Children’s Fund, 58 pp.

Wiesmann, D. 2004. ‘An International Nutrition Index: Concept and Analyses of Food Insecurity and Undernutrition at Country Levels’. Development Econom-ics and Policy Series No. 39.

World Bank. 2008. Of Taps and Toilets: Evaluating Community-Demand-Driven Projects in Rural India, World Bank, Social, Environment and Water Resources Management Unit, Sustainable Development Department, South Asia Region, Report No 43344-IN, 151 pp.

PART III INTENSIFICATION OF

AGRICULTURE, WATER AND HEALTH

158 Nalini Sankararamakrishnan and Leela Iyengar

Arsenic Contamination, Toxicity and Health Effects 159

8

Arsenic Contamination, Toxicity and Health Effects

Cases from India and Bangladesh

NALINI SANKARARAMAKRISHNAN AND LEELA IYENGAR

INTRODUCTION

ARSENIC CONTAMINATION IS widespread in India, Bangladesh, Cambodia, Lao PDR, Mongolia, Vietnam, Myanmar, Nepal and Pakistan, exposing around 140 million people to its harmful toxic effects. The presence of arsenic in groundwater at concentrations beyond the permissible limit of 0.05 mg/l (WHO 1993), (WHO’s current provisional specifi cation: 0.01 mg/l) was reported in the state of West Bengal in India in 1978 (Acharyya et al. 2000), and the fi rst case of arsenic poisoning was diagnosed in 1983 (Garai et al. 1984). In Bangladesh, arsenic contamination of groundwater was fi rst detected in 1993 by Department of Public Health Engineering (DPHE) in an area bordering West Bengal—Chapai Nawabganj—but it was not until 1995 that extensive occurrence of high arsenic was widely known (Dhar et al. 1997, WARPO 2000). With a massive number of people exposed in Bangladesh, many often term this health crisis as the worst geo-environmental calamity in the world. It is worth mentioning that arsenic toxicity in eastern India and Bangladesh was recognised only after extensive exploitation of groundwater for irrigation and drinking water. Once exposed to human body, arsenic is transported through blood to different organs, mainly in the form of Monomethylarsonic (MMA), causing a variety of adverse health effects such as dermal changes—pigmentation, hyperkeratoses and ulceration—and respi-ratory, pulmonary, cardiovascular, hematological, hepatic, renal, neurological, developmental and reproductive problems. It also leads


to decreased IQ, Diabetes mellitus and other carcinogenic effects. Increased foetal loss, premature delivery and decreased birthweight of infants can occur even at low (<10 μg/L) exposure levels.

This chapter reviews the research studies and reports on arsenic and human health to understand research challenges involved in understanding the inter-linkages between arsenic and human health. It presents the contamination status of arsenic, exposure routes, its health effects and the research gaps to tackle this calamity.

EXTENT OF ARSENIC CONTAMINATION

In the Indo-Gangetic region, statistics indicate that 61 out of 64 districts of Bangladesh and 19 districts in the eastern state of West Bengal have been affected by arsenic contamination (Talukder et al. 1998). Arsenic has contaminated the groundwater in 85 per cent of Bangladesh and about 104.9 million people are at risk (Table 8.1). In India, the nine worst affected districts in West Bengal are Bardhaman, Howrah, Hoogly, Kolkata, Malda, Murshidabad, Nadia, North 24 Parganas and South 24 Parganas.

It is now known that many states along Ganga–Meghna–Brahmaputra (GMB) plain in India, such as Bihar, Uttar Pradesh, Jharkhand, Assam and Manipur, have also reported arsenic contami-nation of groundwater. Chronology of arsenic poisoning in GMB is given in Table 8.2. It is reported that parts of all the states surveyed in the GMB plain, which has an area of approximately 500,000 km2 and a large population, may be at risk from groundwater arsenic contamination (Chakraborti et al. 2004).

Although some quantity of arsenic is naturally present in all rocks and sediments that form aquifers tapped for drinking water (Table 8.3), arsenic becomes a public health risk when it is released from the aquifer rock or sediment into groundwater and that groundwater is subsequently used for drinking. In most cases, the arsenic found in rocks and sediments is immobile; as a result, only traces of arsenic are found in groundwater. However, certain natural geo-chemical condi-tions and processes can lead to high levels of arsenic in groundwater. It is these geo-chemical triggers, more than the arsenic content in aquifer, which contaminates drinking water.


Tab

le 8

.1:

Stat

isti

cs o

f Ars

enic

Cal

amit

y in

the

Indo

–Gan

geti

c R

egio

n

Phys

ical

Par

amet

ers

Wes

t Ben

gal,

Indi

aBa

ngla

desh

Num

ber o

f dist

ricts

1964

A

rea

8,87

5014

7,57

0 km

2

Popu

latio

n80

.2 m

illio

n14

1 m

illio

n

WH

O a

rsen

ic d

rinki

ng w

ater

stan

dard

0.

01 m

g/l

0.01

mg/

l A

rsen

ic d

rinki

ng w

ater

stan

dard

0.

01 m

g/l

0.01

mg/

l N

umbe

r of d

istric

ts su

rvey

ed fo

r ars

enic

con

tam

inat

ion

1964

Num

ber o

f dist

ricts

hav

ing

arse

nic

abov

e 0.

05 m

g/l i

n gr

ound

wat

er9

61

Are

a of

affe

cted

dist

ricts

38

,861

km

212

6,13

4 km

2

Popu

latio

n at

risk

50

.4 m

illio

n10

4.9

mill

ion

Pote

ntia

lly e

xpos

ed p

opul

atio

n (d

rinki

ng w

ater

hav

ing

mor

e th

an 0

.050

mg/

l ars

enic

)4.

6 m

illio

n32

mill

ion

Num

ber o

f pat

ient

s suf

ferin

g fr

om a

rsen

icos

is 13

,137

8,50

0

Sour

ce:

http

://w

ww

.soes

ju.o

rg/a

rsen

ic/w

b.ht

ml a

nd G

oB (2

008)

.


There are the following four main geo-chemical processes that trigger the natural release of arsenic from an aquifer into groundwater (UNICEF 2008).

a) Conversion of arsenic-rich ferrous sulfi de to ferric hydroxide in the presence of oxygen and specifi c bacteria,

b) Reduction of iron oxyhydroxides and release of adsorbed arsenic into groundwater,

c) Arsenic mobilisation by exchange of sorbed arsenic with phos-phate and/or bicarbonate, and

d) Mobilisation of arsenic due to geo-thermal activity.

Recently, models based on geo-hydrological data as well as surface parameters have been developed for predicting arsenic concentration in groundwater (Amini et al. 2008, Van Geen et al. 2006, Winkel et al. 2008).

Table 8.2: Chronology of Arsenic poisoning in GMB, India

Year Location Source1976 Chandigarh Datta and Kaul (1976) 1984 West Bengal Garai et al. (1984)1995 West Bengal incident comes

to limelightInternational conference (1995)

2002 Bihar Chakraborti et al. (2003) 2003 Uttar Pradesh Chakraborti et al. (2004)2004 Jharkhand Chakraborti et al. (2004) 2004 Assam Chakraborti et al. (2004) 2006 Manipur Singh (2004), Chakraborti et al. (2008)

Table 8.3: Arsenic in Rock and Sediment

Rock or Sediment Type

Arsenic content (mg/kg)

Average Range

Sandstone 4.1 0.6–120 Limestone 2.6 0.4–20 Granite 1.3 0.2–15 Basalt 2.3 0.2–113 Alluvial sand (Bengal) 2.9 1.0–6.2 Alluvial silt (Bengal) 6.5 2.7–15 Loess (Argentina) – 5.4–18


ARSENIC TOXICITY AND ENVIRONMENT

There are three major possible routes of arsenic exposure: inhalation (Pal et al. 2007), ingestion (Huq and Naidu 2003) and dermal contact (Watts and Halliwell 1996). Among the many possible pathways of arsenic ingestion (Mondal and Polya 2008), drinking water is con-sidered the most signifi cant exposure route (Cantor and Lubin 2007, Smith et al. 2000 and Smith et al. 2006). However, the chronic arsenic toxicity symptoms recorded in various parts of Bangladesh and in West Bengal in India refl ect pathways other than the consumption of water (Huq and Naidu 2003). Soil-crop-food transfer as well as cooking in arsenic-rich water are also considered among the major exposure pathways (Alam et al. 2003, Mondal and Polya 2008).

Arsenic exists in organic and inorganic forms. Organic arsenic exists in seafood but is eliminated by the human body. Inorganic arsenic is considered toxic. Exposure to high levels of toxic arsenic leads to vari-ous health hazards. There are many recent reviews on the health effects of arsenic (Ana Navas-Acien et al. 2005, Bates et al. 1992, Chen et al. 2004, Kapaj et al. 2006, Mandal and Suzuki 2002, , Vahidnia et al. 2007, Villaescusa and Bollinger 2007). Some of these effects are briefl y summarised in Table 8.4. Arsenic tends to accumulate in the skin. Skin hyper-pigmentation and hyperkeratosis have long been known as the hallmark signs of chronic arsenic exposure. These skin lesions develop after 5–10 years of exposure, although shorter latencies are possible. Chronic inhalation of inorganic arsenic causes non-melanoma skin cancer, and is also associated with increased risks of cancer of internal organs (Bates et al. 1992).There are signifi cant associations between these dermatological lesions and risk of skin cancer.

ARSENIC POISONING

Neurological Effect

Several studies indicate that ingestion of inorganic arsenic can result in neural injury. Neurological effects of arsenic may develop within a few hours after ingestion, but usually are seen within two–eight weeks after exposure. The predominant clinical features of neuropathy are numbness and pain, particularly in the soles of the feet. After ingestion, arsenic reacts with the thiol group of proteins and enzymes and inhibits

164 Nalini Sankararamakrishnan and Leela IyengarT

able

8.4

: C

ase

Stud

ies

on S

kin

Lesi

ons

Loca

tion

Tot

al N

umbe

r of

Peo

ple E

xam

ined

Perc

enta

ge/N

umbe

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Dia

gnos

ed p

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nce

Refe

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e

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r co

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angl

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h

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kin

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nM

ales

are

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tible

to

skin

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an fe

mal

esR

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t al.

2006

Mur

shid

abad

, Ind

ia(1

) 25,

274

19%

peo

ple

with

regi

ster

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s M

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epen

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dia

522

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ple

with

skin

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2008

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their catalytic activity. This causes changes in cytoskeletal protein composition and hyperphosphorylation. These changes may lead to disruption of the cytoskeletal framework (Vahidnia et al. 2007).

Chronic exposures (0.05–0.5 mg arsenic kg−1 per day) cause sym-metrical peripheral neuropathy, which begins as numbness in the hands and feet but later may develop into a painful ‘pins and needles’ sensation (Wagner et al. 1979) on the wrist or ankle drop (Chhuttanni et al. 1967).

Cancer

It is already known that cigarette smoking is the primary risk factor for lung cancer, but researchers have now found that cigarette smoking along with ingestion of arsenic affected water has a lethal effect. An 8–year study (Chen et al. 2004) in Taiwan was conducted in arsenic endemic areas. Increased risk of lung cancer was observed in residents drinking water contaminated with arsenic. They suggested that reduction in arsenic exposure may reduce the risk of lung cancer in cigarette smokers. Ferrecio et al. (2000) presented a positive correlation between ingestion of inorganic arsenic and lung cancer among people in Chile. In a study of arsenic in drinking water in West Bengal, India, Mazumder et al. (2003) noted incidence of coughing in 89 out of 156 patients (57 per cent) with arsenical hyperpigmenta-tion. Lung-function tests performed on 17 of those patients showed features of restrictive lung disease. Smith et al. (2002) quotes, ‘The estimated cancer risk at the drinking water standard of 50μg/l for arsenic is more than 100 times greater than that for any other drink-ing water contaminant.’

CHILDREN ADVERSELY AFFECTED

Researchers found that consumption of water contaminated by arsenic was associated with reduced intellectual function in a dose–response fashion (Granzio 2004). Children, with exposure above 50 μg/l had signifi cantly lower performance and full scores compared to children with exposure under 5.5 μg/l. (Intelligence Quotient [IQ] is a gen-eral determination of the capacity of individuals to think and reason.


Tab

le 8

.5:

Cas

e St

udy

on L

ung

Can

cer

in B

angl

ades

h

Num

ber

of P

eopl

e Ex

amin

edN

umbe

r of

Dia

gnos

ed P

eopl

e w

ith L

ung

Can

cer

Num

ber

of P

eopl

e D

iagn

osed

with

N

on- m

alig

nant

Les

ions

Infe

renc

eSo

urce

7,28

63,

223

1,58

8A

rsen

ic a

t >10

0 µg

/l co

ncen

trat

ion

in

drin

king

wat

er is

may

ca

use

incr

ease

d ris

k of

lu

ng c

ance

r.

Mos

tafa

et a

l. 20

08


An IQ level indicates how one is positioned compared to the major-ity of individuals in a given age bracket. It is graphically based on the response to test.) The children with the highest quartile of water infected with arsenic also had marginally reduced verbal scores (Tibbetts 2004). Cross-sectional investigation of intellectual func-tions in 201 children of 10 years of age in Araihazar, Bangladesh, was studied (Wasserman et al. 2004). It was concluded that exposure to arsenic from drinking water was associated with reduced intellectual function. Children with arsenic levels > 50 μg/l achieved signifi cantly lower performance and full-scale scores compared to children with arsenic levels < 5.5 μg/l. A similar result of a case study is shown in Table 8.6 where the children in age group of 5 to 15 years were monitored for their intellectual function.

Table 8.6: Case study on Memory and Intellectual Function in West Bengal, India

Number of Children in the Age Group of 5–15 years Inference Source

351 12% decline in vocabulary test scores21% decline in object assembly test scores13% decline in picture completion test scores

Von Ehrenstein et al. 2007

A case study was conducted by Mazumder et al. (2003) in South 24 Paraganas, an arsenic-affected district in West Bengal. Details of this study are depicted in Table 8.7. In this study the authors have concluded that arsenic not only causes lung cancer but ingestion of high concentrations of arsenic in drinking water may also cause brochiectasis.

A systematic review of the epidemiologic evidence on the associa-tion between arsenic and cardiovascular outcomes has been performed (Ana Navas-Acien et al. 2005). Lee et al. (2002) reported that arsenic ingestion affects the platelets. Platelets are key players in cardiovas-cular disease. In the presence of thrombin, arsenite was observed to increase platelet aggregation. Lee et al. (2002) indicated that platelet aggregation increased with long-term exposure to arsenic water, thereby increasing the risk of cardiovascular disease. Several cases of


Tab

le 8

.7:

Cas

e St

udy

on th

e B

ronc

hiec

tasi

s Ef

fect

of A

rsen

ic in

Wes

t Ben

gal,

Indi

a

Num

ber o

f Peo

ple

Exam

ined

Mea

n St

anda

rd D

evia

tion,

Br

onch

iect

asis

Scor

eIn

fere

nce

Sour

ce10

8 w

ith sk

in

lesio

ns a

nd15

0 w

ithou

t ski

n le

sions

3.4

(± 3

.6) i

n 27

par

tici-

pant

s with

skin

lesio

ns a

nd0.

9 (±

1.6

) in

11 p

artic

i-pa

nts w

ithou

t the

se le

sions

Subj

ects

with

ars

enic

-ca

used

skin

lesio

ns h

ad a

10

-fol

d in

crea

sed

prev

alen

ce o

f Bro

nchi

ecta

sis

com

pare

d to

subj

ects

who

di

d no

t hav

e sk

in le

sions

(a

djus

ted

odds

ratio

± 1

0;

95%

con

fi den

ce in

terv

al ±

2.

7–37

).

Maz

umde

r et a

l. 20

03


heart attack and arterial thickening of children who consumed water containing 600 µg of arsenic were reported. Ischemic Heart Disease (ISH), localised tissue Anaemia due to obstruction of the infl ow of arterial blood was also reported (Chen et al. 1996). Mortality rates due to ISH among residents of 60 villages in Taiwan with endemic arseniasis from 1973 through 1986 were analysed to examine their association with arsenic concentration in drinking water. Based on 1,355,915 person-years and 217 IHD deaths, the cumulative IHD mortalities from birth to age 79 years were 3.4, 3.5, 4.7 and 6.6 per cent, respectively for residents who lived in villages in which the median arsenic concentrations in drinking water were <0.1, 0.1 to 0.34, 0.35 to 0.59, and ≥0.6 mg/l (Chen et al. 1996).

A study conducted in Bangladesh on 48 foetal samples from preg-nant woman with arsenicosis shows that signifi cant levels (>5μg/ in plasma) of arsenic crossed the placental barrier and was transferred from the mother to the foetus through the umbilical cord, particularly in the third trimester (Rahman et al. 2006). Based on population density it is estimated that the number of pregnant women and neo-nates exposed to blood and plasma arsenic concentration above 5μg/l through milk, food and water would be in millions. The study also confi rmed that arsenic is transferred from the mother to the foetus, the adverse consequences of which are not clear but are most likely to be gynaecological—pregnancy-related complications to the mother—disrupting the embryonic development of the foetus and eventually the offspring. In a study by Chakraborti et al. (2003) pregnancy complications were found to be due to chronic exposure to arsenic in groundwater. They found that women with increased arsenic exposure suffered increased foetal loss and premature delivery.

Arsenic contamination has also been associated with diabetes. Chen et al. (2007) have recently reviewed the epidemiological studies on the association between long-term arsenic exposure and the risk of diabetes and hypertension. They concluded that there is a clear dose response relationship with arsenic level in drinking water and the increased prevalence of diabetes mellitus and hypertension among residents in the highly exposed areas of Taiwan and Bangladesh. Arsenic is thought to be an endocrine disruptor, able to alter hormone gene transcription at doses as low as 0.4 μg/l arsenite. Kaltreider et al. (2001) show that


very low levels of arsenic—equivalent to about 10 parts per billion—selectively inhibit the ability of glucocorticoid and its receptor to turn on genes normally under glucocorticoid control. The levels capable of endocrine disruption are far below those necessary to cause cell toxicity.

In West Bengal, India, people are endemically exposed to more than 50 μg/l arsenic in drinking water. Patients complained of irritability, lack of concentration, depression, sleep disorders, headaches, fatigue, skin itching, burning of eyes, weight loss, anemia, chronic abdominal pain, diarrhoea, edema of feet, liver enlargement, spleen enlargement, cough, joint pain, decreased hearing, decreased vision, loss of appetite and weakness. Liver enzymes were increased and liver histology showed fi brosis—fi brotic tissue in liver). It was found that the longer the time of exposure, the more severe the signs and symptoms of arsenic toxicity (Mukherjee et al. 2003, Mazumder et al. 2003, Kapaj et al. 2006)

OVEREXPLOITATION OF GROUNDWATER Considering that groundwater is a free commodity and available in plenty, negligence and lack of awareness on part of the community and local governance often leads to overexploitation of groundwater. Due to absence of vigilance and fl outing of government norms in both India and Bangladesh, there has been indiscriminate sinking of irrigation wells and extraction of groundwater (GoWB 2005). Many irrigation wells are very close to each other and their simultaneous operation often leads to fall of water table in aquifers. In the Indian state of Uttar Pradesh the government sponsored free borings in 1984–85 resulted in over exploitation of groundwater. From 1985 to 2002 the total number of free borings stood at 2.5 million (Pant 2004). In West Bengal, jute, a major cash crop, requires a huge amount of water during the fi bre extraction process. Often the farmers draw groundwater to fi ll up dry ponds for processing jute fi bre. In fresh water fi sh farming, dried small ponds are often fi lled up with ground-water. Paradoxically, large old lakes and water bodies are drained out to use the land for crop cultivation. This practice indicates the lack of macro-level planning and poor understanding of sustainable develop-ment. Groundwater trading by irrigation pump owners has become


an integral part of current rural economy in India and Bangladesh (Rawal 2001).

Introduction of modern agricultural practices have encouraged and promoted farmers to use chemical fertilisers. Three major types of fertilisers are used—nitrogen, phosphate and potassium. Among these, use of phosphate fertiliser causes arsenic leaching of ground-water (Acharyya 2000). From 1992 to 2001, the use of phosphate fertilisers in West Bengal increased from 0.2 to 0.32 million metric tons (GoWB 2003).

SOCIO-ECONOMIC STATUS AND SEVERITY OF MANIFESTATION

Poor people are the worst sufferers of arsenic poisoning as they are more vulnerable to contaminated water and have little or no alternative solutions. Indeed, poverty is associated with lack of food and nutrition security (Sarkar 2004a, Hanchett 2004). A population-based study conducted in Murshidabad district of India found that 73 per cent of the irrigation wells and 62 per cent hand pumps used for domestic purposes were contaminated with arsenic (Sarkar 2004b). Poor agri-cultural labourers, who spend almost half a day in farm lands, drink arsenic contaminated water from irrigation wells. Thus poor farmers are doubly exposed to this contamination both at home and at their workplaces. Richer households have better access to information and more fi nancial capacity to spend on alternative solutions, like sinking newly dug wells or buying arsenic removal fi lters for domestic use. Also, they visit the fi elds only for supervision of agriculture activities. The richer inhabitants also have more political infl uence to divert govern-ment funds and schemes for personal gains, for instance, installation of arsenic removal fi lters near their homes.

Studies of large populations all fi nd prevalence of arsenicosis sym-ptoms to be signifi cantly higher in males than females (Yunus 2003, AAN 2004). One smaller study, however, have identifi ed larger percentages of women are affected than men among arsenic affected patients in Bhanga Upazila, Faridpur district (58.6% of 488 patients) and in Barura Upazila, Comilla (62% of 58 patients (WHO 2002). It is important to note that in any public screening or health camp


women will not receive as much attention as men because of their reluctance to be examined by male physicians. Furthermore, smaller study populations will have statistically variable characteristics (Hanchett 2004).

General health services are of poor quality in the region, largely due to lack of infrastructure, manpower and motivation. Most of the curative management of patients suffering from arsenic related mani-festations is essentially available in cities with the rural population having no access to it. In the current scenario, only the rich and middle class people can afford treatment of arsenic poisoning. Further, in many cases, patients have complained of recurrence of symptoms after treatment, due to re-exposure to contaminated water. Field visits have revealed increase in number of arsenicosis cases and deaths as well, but the majority of them have not been reported in local government hospital registers due to poor surveillance system (Sarkar 2006).

The arsenic problem has now produced a crowded fi eld in which numerous agencies—government, non-governmental organisations, UN, religious and volunteer groups—rush to villages to implement schemes that are not well coordinated. The different methods employed in tubewell testing and differing ideas deployed to solve the contamination problem only confuses people and reduces the chances of drastic improvement in the affected community.

CONCLUSIONS Arsenic contamination is a global problem. Compared to other countries, the number of people at risk is considerably higher in the Indo–Gangetic region of Bangladesh and India. Thousands of arsenic affected patients have already been identifi ed. If the people continue to use arsenic-contaminated water, millions will lose their health or die within a few decades. Those who may survive are in danger of carry-ing genetic diseases to future generations. Hence, there is an urgent need to tackle the problem by means of community participation, strengthening local governance and advocating interdisciplinary strat-egies. However, several gaps exist in the scientifi c knowledge about arsenic contamination and its effect. This hampers policy decisions to develop sustainable mitigation measures. Some of the gaps identifi ed in this chapter are:


1. The health impact of arsenic in the presence of other pollutants and iron has not been fully studied. It is imperative to know if the presence of other pollutants worsens the arsenicosis conditions.

2. Most studies have focused on physical cause–effect linkages, and have failed to generate comprehensive understanding of the role of natural and man-made process in releasing arsenic into water.

3. Ingestion of arsenic through other routes, such as contaminated food, has not been adequately studied. A vast majority of the contaminated groundwater is utilised for irrigation purposes. The potential leakage of arsenic into plants and foods, its reten-tion in soil and its leaching back to shallower aquifers have not been investigated.

4. Soil retention of arsenic can lead to arsenic-laden dust particles; these have not been explicitly studied as an ingestion route.

5. Research should also be focused on the prevention of arsenic leaching due to phosphate-free fertilisers by using green manures.

The international community has the economic resources, environ-mental expertise and technologies to mitigate the arsenic contamina-tion in groundwater. The support of UN, donor countries, donor organisations, agencies and individuals is essential to save the suffering people from the devastating arsenic disaster.

RECOMMENDATIONS

Awareness generation among people regarding arsenic contamination and its ill-effects is of the top most priority in arsenic-affected areas. Proper monitoring of water sources is essential and sources more than the WHO limit should be marked in red and people should be instructed to use that source only for washing purposes. Switching to safe water sources, namely deep tubewell, dug well, rain water or surface water can be carried out. It is highly desirable to form a research group consisting of geologists, hydrologists, geo-chemists, water supply and environmental engineers, and public health experts to conduct in-depth investigation on the sources and causes of arsenic


contamination in groundwater. National level groundwater policy should aim to reduce the exploitation of groundwater resources. In areas which lack alternative safe water sources, low-cost domestic fi lters could be provided. However, regular monitoring of the fi lter and proper disposal of arsenic laden wastes should be carried out. Usage of arsenic contaminated groundwater for agriculture should be avoided to prevent the arsenic exposure from food grains.

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180 Mohua Guha and Kamla Gupta

9

Arsenic Pollution and Reproductive Health

A Case Study of Murshidabad District in West Bengal

MOHUA GUHA AND KAMLA GUPTA1

INTRODUCTION WATER IS ESSENTIAL to sustain life and adequate, safe and accessible supply must be available to all. It has been increasingly documented that improving access to safe drinking water can result in tangible bene-fi ts to health (Cvjetanovic 1986, Esrey and Habicht 1986). Diseases related to contamination of drinking water constitute a major burden on human health and studies show water contaminants to be associated with poor reproductive health of women (Schettler et al. 1999).

Exposure to toxins in water can damage female reproductive func-tion and health in a variety of ways. Some exposures cause structural malformations and diseases; others more subtly damage tissues or cells of reproductive organs. Exposure has also been linked to impaired fertility, menstrual disorders, illness during pregnancy, adverse foetal outcomes, ovarian failure, early onset of menopause as well as to a higher risk of cancers, diseases and disorders of the female reproduc-tive tract and ovaries (Schwartz and Woodruff 2008). Interventions to improve the quality of drinking water can provide signifi cant benefi ts to the health and well-being of women. Thus, there is an urgent need to initiate a collective endeavour to understand the effects of chemical exposures on fertility and reproductive health,

1 The fi nancial assistance for the fi eld study was provided by the Parkes Foundation Small Grants Fund, Department of Biological Anthropology, Cambridge University, UK. The authors express their sincere gratitude to Prof. Dipankar Chakraborti, Director, SOES, Jadavpur University and all his staff members for necessary help and support.

Arsenic Pollution and Reproductive Health 181

and to leverage this understanding to create healthier environments for reproduction through policy change, improved medical care and public awareness.

Among chemical contaminants, the occurrence of arsenic in groundwater constitutes a serious impediment in the provision of safe drinking water. The International Agency for Research on Cancer (IARC) has classifi ed arsenic as a Group 1 human carcinogen (IARC 2001). The World Health Organization (WHO) recognises arsenic as the most serious inorganic contaminant in groundwater with toxic properties (WHO 1981). While the earlier maximum allowable con-centration recommended by WHO was 0.05 milligram/litre (mg/l), in 1993 the provisional guideline value was reduced to 0.01 mg/l or 10 parts/billion (ppb) based on concerns regarding its carcinogenicity in humans (WHO 2001). The WHO guidelines are intended to be a basis for setting national standards to ensure the safety of public water supplies.

In developing national drinking water standards based on the guideline values, it is necessary to take into account a variety of geographical, socio-economic, dietary and other cultural conditions affecting potential exposure, which lead to national standards that dif-fer considerably from the guideline values. Therefore, most developing countries, including India, still use the former WHO recommended concentration of 0.05 mg/l as the national standard, partially due to economic considerations and also the lack of epidemiological evidence of human data at low concentrations.

Since the early 1980s, a number of studies have been conducted to assess and quantify the impact of ingesting arsenic-contaminated groundwater. However, in spite of more than three decades of research and interventions, no clear picture has yet emerged of the arsenic epidemiology in the affected regions. Though it is clear that there are major effects, and millions of people are at risk from arsenic-induced diseases, especially skin lesions, there is still uncertainty regarding the exact number of arsenic patients. The major diffi culties for epidemio-logical research lie in the quantifi cation of exposure intensity. There is enormous geographical variation in concentrations of arsenic in tubewell water within the same village, with little evidence of tem-poral and seasonal variations in concentration, even from the same


tubewell (Concha et al. 2006, van Geen et al. 2003, Xavier et al. 2006). Therefore, most studies are limited by several acknowledged assumptions (Guha 2003, Haque et al. 2003).

Besides, the populations at risk are mostly the rural people, as arsenic removal technologies are more effectively implemented in urban areas, where water is supplied through a centralised system after proper treatment and distillation, for example in parts of Kolkata urban area. Addressing arsenic contamination is a major fi nancial and management challenge in villages where scattered small communi-ties are affected. India so far has spent $3 million on arsenic removal plants (ARPs) to capture the dissolved arsenic using ferric salts. Of the 2,000 installed ARPs in the villages of West Bengal, 4 out of 5 are either abandoned or deliver smelly and discoloured water. A study conducted by Hossain et al. (2005) investigating the effi ciency of ARPs in West Bengal reported that out of 20 ARPs, 15 were found in good working condition; of which 8 were not useful in removing arsenic according to the Indian standard value of arsenic in drinking water and 14 (93.3 per cent) were not useful in removing arsenic according to WHO recommended value of arsenic in drinking water. It further states that though the treatment plants were installed for supplying safe water, the endeavour failed because of technological limitation of the plants, lack of proper service and maintenance, lack of peoples’ participation, lack of people’s awareness, lack of education and training, village politics, poor socio-economic condition, and so on. Thus in the villages in West Bengal, development of such tech-nology is possible only when bureaucrats, technocrats and villagers cooperate with proper village level participation. Sadly, for poor rural communities, water is the source of their livelihood and when it is unclean or polluted, it actually becomes a cause of ill-health and continued poverty.

ARSENIC EXPOSURE AND HEALTH EFFECTS

The scale of the problem in terms of population exposed to high arsenic concentration is the greatest in Bangladesh, with an estimated 35 to 77 million, that is around 28 to 62 per cent of the total population of 125 million, at risk of consuming arsenic-contaminated water


(Alam 2000, Smith et al. 2000). The worst arsenic-affected state in India is West Bengal, where more than six million people from nine districts, with a total population of 50 million, out of 19 total dis-tricts, with a total population of 80 million,, drink water containing ≥0.05 mg/l arsenic, and more than 300,000 people are reported to have visible arsenical skin lesions (Chakraborti et al. 2002).

Besides West Bengal, arsenic in groundwater was reported from several villages in Bihar (Chakraborti et al. 2003) and three districts—Ballia, Gazipur and Varanasi—from Uttar Pradesh (SOES 2004). Arsenic contamination has also been reported from four blocks in Jharkhand (SOES 2005: 1–16), a few villages in Chhattisgarh (Chakraborti et al. 1999), Madhya Pradesh (Pandey et al. 1999) and Andhra Pradesh (Dhar et al. 1998, Govil et al. 2001). Arsenic con-centration exceed the permissible level in the north-eastern states of Assam (20 of 24 districts), Tripura (3 of 4 districts), Arunachal Pradesh (6 of 13 districts), Nagaland (2 of 8 districts), and Manipur (1 of 9 districts), according to the 2004 report of the North Eastern Regional Institute of Water and Land Management.

The fi rst cases of arsenicosis in the Bengal Basin of India were identifi ed in 16 patients from a village in July 1983 (Chakraborty and Saha 1987, Garai et al. 1984, Saha 1984) but widespread con-tamination was not defi ned until 1995. The analytical test results of SOES, Jadavpur University, Kolkata, indicate that 48.2 per cent of the tubewells have arsenic concentrations of >0.01 mg/l and 23.9 per cent have >0.05 mg/l. Nine of the 19 districts are severely affected (>0.05 mg/l), fi ve each are in the mildly-affected (concentrations <0.05 mg/l) and safe (<0.01 mg/l) categories (Mukherjee et al. 2006). Analyses of biological samples indicate that many people in the susceptible villages may be sub-clinically affected (Chakraborti et al. 2003, Das et al. 1995). Epidemiological studies have shown evidence of arsenical dermatoses among 92 per cent of the population exposed to arsenic in the concentration of 0.20–2.0 mg/l in contrast to about six per cent of the population with less than 0.05 mg/l in drinking water (Chakraborti et al. 2002).

Arsenic is a known carcinogen and has long been associated with toxic effects, ranging from acute lethality to chronic effects. The effects


may be both local and systemic but chronic exposure usually affects all the organs and systems of the human body including skin, liver, respiratory, gastro-intestinal, cardiovascular, immune, genitourinary, nervous and reproductive systems (Abernathy et al. 1997: 55-68). Adverse health effects are usually manifested among the population within a span of 8 to 10 years after initial exposure (Das et al. 1994, Guha Mazumdar et al. 1988), while the minimum duration for developing manifestation was found to be eight months (Rosenberg 1974). Incubation differs from person to person depending on the concentration and duration of exposure and possibly on interaction with nutritional and genetic factors and the immunity of the individual (National Research Council 1999).

Given the methodological limitations of the epidemiologic evidence implicating arsenic as a reproductive toxin, the literature on adverse reproductive outcomes is suggestive, but not yet conclusive (Golub et al. 1998). In humans, studies observed that arsenic readily crosses the placental barrier, giving rise to concentration that is about as high in cord blood as in maternal blood and thus affects foetal development (Concha et al. 1998a). Though there are few data on the reproductive effects of arsenic in humans, collective evidence suggests the potential for adverse effects on several reproductive end points. This includes increased evidence of foetal, neonatal and postnatal mortalities, and elevations in low birthweight, spontaneous abortion, stillbirth, preterm birth, pre-eclampsia, and congenital malformations.

Ecologic studies of populations exposed to arsenic in countries like Argentina (Concha et al. 1998b), Chile (Hopenhayn-Rich et al. 1998, 2000, 2003), Hungary (Borzsonyi et al. 1992, Desi 1992, Rudnai and Gulyas 1998), Sweden (Nordstrom et al. 1978a, 1978b, 1979) and Taiwan (Yang et al. 2003) have also suggested associations between high arsenic exposure and spontaneous abortion, stillbirth, preterm birth, low birthweight and peri-natal and neonatal mortality. In the United States of America, three studies reported adverse reproductive effects, including increases in mortality from congenital cardiovascular anomalies (Engel and Smith 1994, Zierler et al. 1988) and spontan-eous abortions (Aschengrau et al. 1989).


In some villages in the Middle Ganga Plain of India,2 an increase in foetal loss and pre-mature delivery was observed among women with high arsenic concentrations in their drinking water (Chakraborti et al. 2003). Studies from Bangladesh and West Bengal in India suggest that such effects are not improbable, and evidences implicate that arsenic concentration in the urine samples of pregnant women refl ect their level of chronic exposure (Vahter et al. 2006). Other studies in the endemic areas of the Bengal Basin have observed increased susceptibil-ity of pregnant women to spontaneous abortions, stillbirths, preterm deliveries and low birthweight (Chakraborti et al. 2004, Mukherjee et al. 2005, von Ehrenstein et al. 2006). Studies in Bangladesh have also shown signifi cant association between arsenic exposure and adverse pregnancy outcomes including birth-defects (Ahmad et al. 2001,Cherry et al. 2008, Kwok et al. 2006, Milton et al. 2005).

With this background, the aim of our study was to examine the adverse outcomes of pregnancy in terms of live births, stillbirths, spontaneous abortion and preterm birth and among women of the exposed group consuming drinking water above the national stand-ard for arsenic concentrations compared to the non-exposed group consuming drinking water below the national arsenic concentrations standard.

ARSENIC POLICIES AND MITIGATION MEASURES IN WEST BENGAL: AN OVERVIEW

In 2001–02 nearly 1.7 million people were clinically diagnosed with arsenic-related skin manifestations in West Bengal (PHED 2001–02), and the government has adopted several preventive measures to address

2 Middle Ganga Plain: The Gangetic Plain is divided into three parts—Upper Ganga Plain, Middle Ganga Plain and Lower Ganga Plain. The Middle Ganga Plain covers about 89 per cent of the geographical area of Bihar or, approximately 94,000 sq. km and holds potential alluvial aquifers. The tract is known for surplus food production and intensive groundwater extraction for drinking, irrigation, and industrial uses. Earlier the Middle and Upper Ganga Plains, which cover the upstream part from Rajmahal Hills, were considered to be free from arsenic groundwater contamination.


this crisis. The constitution of a steering committee (fi rst committee) by the Government of West Bengal (GoWB) in December 1983 was a positive step in this direction. Since then several initiatives undertaken by the state and central governments, in partnership with externally funded agencies, have tried to design and implement successful mitigation measures like ARPs, deep tubewells, dug wells, rainwater harvesting and usage of surface water with proper watershed man-agement and purifi cation. Endeavours also include constitution of expert committees comprising of eminent experts from government organisations and academic institutions, and bringing the arsenic crisis under the aegis of the National Drinking Water Mission.

Several organisations, namely the School of Tropical Medicine (STM); All India Institute of Hygiene and Public Health (AIIH&PH); Central Ground Water Board (CGWB); Geological Survey of India (GSI); Centre for Study of Man and Environment (CSME); Direc-torate of Health Services, GoWB; Seth Sukhlal Karnani Medical Hospital, Kolkata; PHED, GoWB; SOES, Jadavpur University and the National Bureau of Soil Sample and Land Use Planning, are working either individually or collectively in many of the affected districts. Among the donor agencies, the World Bank–United Nations Development Programme (UNDP) Joint Programme on Water and Sanitation have taken a position of leadership and coordination regarding arsenic projects in the state. The WHO is also cooperating with the crash programmes, providing technical support in the form of new analytic equipment and chemical supplies to strengthen the analytical capabilities and providing innovative options for alterna-tive sources of drinking water. In addition, a Joint Plan of Action by the GoWB and United Nations International Children’s Emergency Fund (UNICEF) has been drafted to address the specifi c health needs of the affl icted population (PHED 2002).

This mainly includes:

• Training of doctors and medical offi cers for case detection and treatment

• Training of paramedical staff and health workers for case detec-tion and surveillance

• Training of non-governmental organisation (NGO) workers on case detection and preventive measures


• Capacity of district level hospitals for patient care and treat-ment through creating small arsenic clinic within the district hospital

• Capacity building of health centres, sub-divisional and block level for treatment, drugs and equipments

• Strengthening the monitoring wing at Directorate of Health, Kolkata

• Epidemiological studies on ‘arsenic toxicity’ implications on child health and pregnancy

• Creation of a data base of patients• Development and printing of health-related information, educa-

tion and communication (IEC) materials.

METHODS AND MATERIALS Profi le of the Study District

Murshidabad, one of the nine arsenic-affected districts of West Bengal, extends from 23˚43′30′′ to 24˚50′20′′ North latitudes and 87˚49′ 17′′ to 88˚44′ East longitudes. The river Ganga forms its northern and eastern boundaries and separates it from Bangladesh. The district has 26 blocks, with 2,210 inhabited villages, 262 Gram Panchayats includ-ing municipal areas (known as wards) and 26 Panchayat Samiti(s). With a population of 5,866,569, and extending over an area of 5,324 sq. km, Murshidabad accounts for 7.32 per cent of the population of West Bengal (RGI 2001). Literacy rates, both among males and females are low, with the district ranking third lowest in the state. The economy is purely agrarian in nature with dependence on primary activities. Seventeen per cent of the households live in temporary structures while 45.8 per cent live in semi-permanent structures with no proper water supply and sanitation facilities (RGI 2001). Such statistics reveal the level of deprivation and poverty in the district.

Study Design

A cross-sectional case-control study was conducted in Murshidabad district in 2006. Seventy two per cent of the villages in this district have arsenic concentration above the WHO guideline, among which


75 per cent villages exhibit concentration level above the national standard of 0.05 mg/l. The minimum and maximum concentration varies in the range of 0.01 to 0.90 mg/l, far above the WHO provi-sional guideline value of 0.01 mg/l (GoI 2007). There is no govern-ment statistics on how many hand pumped tubewells (HPTWs) exist in the 26 blocks of the district. There are approximately 0.2 million HPTWs in all the blocks and on an average 35 persons are dependent on one HPTW (Rahman 2003). Among the 26 blocks in the district, 19 are arsenic affected (PHED 2004). Since the level of arsenic contamination varies greatly within the districts, all the blocks were ranked according to their mean level of arsenic concentration, after which they were divided into four quartiles.

The following blocks were selected randomly, one from each quartile: Beldanga I, Nowda, Bhagawangola I and Bhagawangola II. From these blocks, eight villages, two from each block, one above the 50 percentile value and one below it, were chosen as case villages for the study. The villages were ranked according to the mean arsenic con-centration provided by PHED. . The study villages were Makrampur and Bishurpukur (Beldanga I), Madhupur and Gadigacha (Nowda), Asanpara and Jalibagicha (Bhagawangola I) and Badarmati-Sarakpara and Badarmati-Chaipara (Bhagawangola II).

From the remaining seven blocks which were in the safe category—concentration below the national standard—two, namely, Kandi and Khargram were chosen purposively. Two villages each from the two blocks were selected to be used as control villages. These included Banti and Bahara (Kandi) and Balia and Mahisar (Khargram). To ensure comparability of the case villages with the control villages, we followed the guidelines of Schulz and Grimes (2006). However, we restricted the choice of control villages to the same district as the case villages after matching the demographic and socio-economic indicators, such as size, age and sex distribution, religious composition, proportion of Scheduled Caste and Tribe population and female literacy rate, which is necessary for a case-control study. Such information was taken from the Census of India (RGI 2001). In all, 12 villages were selected for this study, eight as cases and four as control.

Almost all the families in the selected villages had access to HPTWs and mostly used tubewell water for drinking and cooking. A sizeable


proportion of the residents in these districts also had privately owned HPTWs within their homes. But the PHED test reports pertain to only those owned by the government. This is one of the limitations of the study. The target population of this study was individual households within selected villages using public HPTWs. Prior to the selection of the respondents, PHED-tested tubewells were identifi ed according to the landmarks provided for the same. A quick fi eld survey was conducted to verify the list. The list contained a few errors which were corrected before randomly drawing fi ve tubewells each from case and control villages. The reason behind choosing fi ve tubewells was purely based on the logic of restricting our sample size to about 360 households. In the study district, approximately 35 persons, or about six households, depended on a single tubewell for water. The Gram Panchayat offi ces of the selected villages helped in tubewell identifi ca-tion and also in preparing a list of households drawing water, mainly for drinking and cooking, from these fi ve tubewells. Using random sampling procedure, six households were then selected from the list of users of each identifi ed tubewell. Though Rahman et al. (2003) found that about six households depended on a single HPTW in the study districts. During pilot survey we found that about 19–26 households were dependent on a single tubewell. We decided that we would randomly select six households from the list of users of a single HPTW in order to reach our decided sample size. Thus the actual number of households surveyed was 367, 247 and 120 households respectively from case and control villages. Out of the 367 selected households, 213 women were eligible for pregnancy related questions. Since there was no list of pregnant women in the past fi ve years, we took the household list as sample frame.

Subject Eligibility

After identifi cation of households, all women living there were identi-fi ed by the interviewers and their eligibility status was determined. Eligible participants included ever-married women of reproductive age 15–49 years, who previously had at least one pregnancy in the last fi ve years. The exposed group consisted of women who had been drinking arsenic-contaminated water (≥0.05 mg/l) for at least fi ve years, whereas the non-exposed group consisted of respondents who


had been drinking arsenic-safe water (≤0.05 mg/l). Out of the total 243 eligible women, 30 declined to participate due to religious reasons and the conservative nature of the local culture. A total of 213 eligible women fi nally agreed to be interviewed.

Data Collection

A semi-structured interview schedule was used to collect quantita-tive information from the respondents after obtaining their verbal consent. There were two broad sections in the interview schedule (a) a household section which was designed to capture the socio-demographic characteristics along with sources and use of water facili-ties for different purposes and (b) the second section tried to capture the individual characteristics of women in their reproductive age (15–49 years), a detailed overview of their pregnancy history, including adverse pregnancy outcomes, that is spontaneous abortion, stillbirth and preterm birth. The interview schedule was pre-tested through a pilot study in March 2006 and the actual survey was conducted between April and July 2006.

Outcome Defi nition

Information was collected on the respondents’ lifetime pregnancy his-tory, which included the number of pregnancies, live births, stillbirths, preterm births and spontaneous abortions. A stillbirth was considered to be any delivery after 28 completed weeks of gestation in which the baby did not breathe or show any sign of life (Dutta 1994). A preterm birth was considered to be any live birth before completion of 8 months, or 37 weeks from the last menstrual cycle (Dutta 1994). A natural failure of pregnancy within the fi rst 28 weeks of gestation was regarded as spontaneous abortion (Dutta 1994). During analysis we calculated stillbirth, spontaneous abortion and preterm birth rates using the total number of live births as the denominator. Subsequently, the pregnancy outcomes have been compared in the exposed and non-exposed groups.

Results

A majority (80.3 per cent) of the respondents in the exposed and non-exposed groups were between 18 and 36 years of age at the time


of the survey. Table 9.1 gives a comparative overview of some of the selected background characteristics of the women in the two groups. The mean ages of the respondents in both exposed and non-exposed groups were 27.7 and 27.1, respectively. Of the respondents in both the groups, 53.6 per cent of women were married in the early age group of 15–19 years. Among the total respondents, 62.3 per cent had no formal education, and only 16 per cent had secondary educa-tion or more. Of the total eligible women, 43 per cent came from households belonging to medium living standard and only 11.1 per cent came from households with high living standard. Moreover, there was no statistically signifi cant difference ( p > 0.05) for standard of living index, age at marriage, and educational level of the respondents belonging to exposed or non-exposed groups. Of the respondents in the exposed group, 81 per cent had been drinking water containing ≥0.05 mg/l of arsenic and 44.3 per cent of these women had been drinking this water for more than 10 years. In the exposed group, 22.9 per cent had skin lesions due to arsenic toxicity.

Table 9.1: Comparable Variables among the Exposed and Non-exposed Groups

VariablesExposed

(n = 117)Non-exposed

(n = 96) Signifi cant Difference

Mean age (years) 27.7 27.1 z = 0.59; p>0.05Mean age at marriage (years) 16.3 16.5 z = 0.36; p>0.05Education

NonePrimarySecondary and above

612316

632017

X 2 = 0.39; p>0.05

Standard of livingLow MediumHigh

325216

284923

X 2 = 0.90; p>0.05

As depicted in Table 9.2, the mean number of pregnancies, live births, stillbirths, spontaneous abortions and preterm births were 3.74, 3.07, 0.18, 0.23, and 0.23 among the exposed group and 3.22, 3.33, 0.07, 0.07, and 0.08 among the non-exposed group, respectively. In the exposed and non-exposed groups, 89 per cent and 95 per cent respectively, of the pregnancies resulted in live births; the difference was statistically signifi cant (z = 3.2; p = 0.002). Adverse pregnancy


outcomes, such as spontaneous abortion, stillbirth and preterm birth rates were 68.8, 53.1, and 68.8 per 1000 live births among the exposed group and 23.7, 23.7, and 27.1 per 1000 live births among the non-exposed group respectively, as shown in Table 9.3. This signifi es that the risks were generally higher for all three pregnancy outcomes among women in the exposed group as compared to the non-exposed group. The results also show a statistically signifi cant difference in the adverse pregnancy outcomes rates (p < 0.05) between these two groups.

Table 9.3: Adverse Pregnancy Outcomes per 1,000 Live Births among the Respondents

Pregnancy Outcomes Exposed Non-exposed

Spontaneous abortion 68.8 23.7Stillbirth 53.1 23.7Preterm birth 68.6 27.1

The pregnancy outcome rates were higher among the exposed group, that is for women who had been drinking arsenic-contami-nated water (≥ 0.05 mg/l) for more than 15 years than among those who had been drinking arsenic-contaminated water for less than 15 years. The rates of spontaneous abortions, stillbirths and preterm births were 43.5, 43.5, and 47.8 per 1,000 live births, respectively, among those women who had been drinking arsenic-contaminated water for less than 15 years, whereas these rates were 133.3, 77.5 and 122.2 per 1,000 live births, respectively, among those women who had been drinking arsenic-contaminated water for more than 15 years. The observed difference was statistically signifi cant (p < 0.05). In accordance with the fi ndings from several earlier studies (Chakraborti et al. 2004, Mukherjee et al. 2005, von Ehrenstein et al. 2006), this study also observed an increase in the rate of spontaneous abortions

Table 9.2: Respondents by Mean Pregnancy Outcomes

Pregnancy Outcomes Exposed Non-exposed

Pregnancy 3.74 3.22 Live birth 3.07 3.33 Stillbirth 0.18 0.07 Spontaneous abortion 0.23 0.07 Preterm birth 0.23 0.08


with increased concentration of arsenic in drinking water. Arsenic concentration level in the case villages were categorised as ≤ 0.1231, 0.1231–0.3564 and > 0.3564 mg/). A 1.4-fold increase in spontane-ous abortion was observed among women in the ‘high’ exposed group (arsenic level of > 0.3564 mg/l) compared to the ‘low’ exposure group, that is arsenic level of ≤ 0.1231 mg/l.

DISCUSSION AND CONCLUSION

In this cross-sectional case–control study, adverse pregnancy outcomes in terms of spontaneous abortions, stillbirths and preterm births were compared between two groups of women, one drinking arsenic-contaminated water (≥0.05 mg/l), and the other drinking arsenic-safe water (≤0.05 mg/l) below the national standard. The groups were comparable with respect to age, age at marriage, level of education, and standard of living status as these variables did not differ statistically. The fi ndings suggest an association between chronic arsenic exposure and spontaneous abortion, stillbirth and preterm birth. Risks were generally higher for all the three pregnancy outcomes with longer duration of arsenic exposure.

Murshidabad is an example of such districts, where the suffering of arsenic-affected villagers has continued unabated over the years. It is important that this issue is noticed by the scientifi c community, and the study reminds them of the urgency to provide safe drinking water to the affected population. Considering the multi-faceted nature of the arsenic problem, the study had some limitations. First, it considered a linear relationship between arsenic-contaminated water and reproduc-tive health. Second, this was not an epidemiological study as we could not carry out a suffi ciently elaborate survey. In West Bengal, especially in the rural areas, the medical records system is still rudimentary and most medical records, even in rural Primary Health Centres (PHCs) are handwritten documents.

With lack of documentation of pregnancy outcomes in the study area, we had to rely primarily on the information provided by the respondents themselves. Hence, there is a chance of recall bias through differential recall of adverse pregnancy outcomes. Interviewer bias is less likely because the interviewers were unaware of the arsenic con-centration levels of the subject’s usual drinking water source.


It would also have been desirable to have directly measured individual exposure data over time, because reports of water testing refl ected only a particular point in time and not the historical expo-sure. However, in the absence of any reliable information on the past exposure, it was necessary to assume that arsenic concentration from the tubewells had been relatively constant over time. Furthermore, we had information about only one tubewell being used by each woman, and so, her cumulative duration of arsenic exposure could not include exposure from other tubewells, especially before their marriage. The amount of drinking water consumed was also not considered in this study. There could be variation in adverse pregnancy outcomes that is related to the amount of the contaminated water the woman drank on an average. The study subjects could not quantify the exact levels of water intake throughout the day.

Nevertheless, the strength of this study is the availability of arsenic exposure data and determination of risk between two exposed groups. The fi eld data support the accumulating evidence that arsenic in drinking water is an important hazard in pregnancy, and every effort is needed to protect women at high risk. However, larger case-control studies are needed to confi rm associations between arsenic exposure and adverse pregnancy outcomes.

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Nordstrom, S., L. Beckman, and I. Nordenson. 1978a. ‘Occupational and Environmental Risk In and Around a Smelter in Northern Sweden. I: Variations in Birth Weight’, Hereditas, 88(1): 43–46.

———. 1978b. ‘Occupational and Environmental Risk In and Around a Smelter in Northern Sweden. III: Frequencies of Spontaneous Abortion’, Hereditas, 88(1): 51–54.

Nordstrom, S., L. Beckman, and I. Nordenson. 1979. ‘Occupational and Environ-mental Risk In and Around a Smelter in Northern Sweden. V: Spontaneous


Abortion among Female Employees and Decreased Birth Weight in their Offspring’, Hereditas, 90(2): 291–96.

North Eastern Regional Institute of Water and Land Management. 2004. Pre-seminar Proceedings from the National Seminar on Arsenic and Fluoride Contamination in Groundwater, pp 1–10.Tezpur, Assam: North Eastern Regional Institute of Water and Land Management, October.

Pandey, P.K., R.N. Khare, S. Sharma, S.K. Sar, M. Pandey, and P. Binayke. 1999. ‘Arsenicosis and Deteriorating Groundwater Quality: Unfolding Crisis in Central East India Region’, Current Science, 77(5): 686–93.

PHED. 2001–02. Health on the March. West Bengal: Public Health and Engineering Department, Government of West Bengal.

———. 2002. Revised Joint Plan of Action for Arsenic Mitigation in West Bengal. West Bengal: Public Health and Engineering Department, Government of West Bengal.

———. 2004. Habitation Survey along with Water Quality Test: Block Wise Report of the District of Murshidabad. Public Health and Engineering Department, Government of West Bengal.

Rahman, M.M. 2003. ‘Present Status of Groundwater Arsenic Contamination in Bangladesh and Detailed Study of Murshidabad, One of the Affected Neighbouring Districts in West Bengal, India’. Ph. D. Thesis, SOES, Jadavpur University, Kolkata.

Rahman, M.M., B.K. Mandal, T. Roychowdhury, M.K. Sengupta, U.K. Chowdhury, D. Lodh, C.R. Chanda, G.K. Basu, S.C. Mukherjee, K.C. Saha, and D. Chakraborti. 2003. ‘Arsenic Groundwater Contamination and Sufferings of People in North-24 Parganas, One of the Nine Arsenic Affected Districts of West Bengal, India: The Seven Years Study’, Journal of Environmental Science and Health, A38(1): 25–59.

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200 Lalit Mohan Sharma et al.

10

Water Quality and Human Health in Mewat

Challenges and Innovative Solutions

LALIT MOHAN SHARMA, ARAVINDA SATYAVADA AND ARCHANA CHOWDHURY

INTRODUCTION

GROUNDWATER IS A vital component of water resource system. Being the largest reserve of drinkable water for human population, ground-water has always been crucial to human civilisation. Groundwater is often utilised for drinking, irrigation and industrial purposes, and is normally preferred as it tends to be less contaminated by wastes and organisms. The deteriorating quality of groundwater due to increas-ing contamination by various toxic substances is a growing concern (Tariq et al. 2008). Groundwater gets depleted when mining is more than the recharge. This further changes the fl ow of the groundwater which in turn causes ingress of sea water, intrusion of other saline groundwater or polluted water from the surrounding areas. The result is that the quality of groundwater is adversely affected. The situation gets further exacerbated in the absence of any regulatory policy for groundwater mining. Health related studies have shown that intake of toxic compounds through water may result in extreme risks including water-borne diseases. In India alone, water-borne diseases annually put a burden of US$ 3.1 to 8.3 million (Mukherjee 2008). One of the major aspects in the deterioration of water quality is an increase in the overall salinity. Saline water has a relatively high concentration of dissolved salts such as cations and anions.

Besides containing sodium chloride, salt also has dissolved Calcium, Magnesium, sulfate, bicarbonate, Boron, and other ions. It is assessed in terms of ‘total dissolved solids’ (TDS) measured in part

Water Quality and Human Health 201

per million (ppm) or mg/l, but approximated by measuring the elec-trical conductivity (EC) of water, expressed in decisiemens per metre (dS/m). The palatability of water with a TDS level of less than 600 mg/l is generally considered to be good (Table 10.1). Drinking water becomes signifi cantly unpalatable at TDS levels greater than 1,000 mg/l (Department of Primary Industries and Fisheries 2008).

Table 10.1: Parametres for Saline Water (in ppm)

Freshwater < 1,000 Slightly saline water 1,000–3,000Moderately saline water 3,000–10,000Highly saline water 10,000–35,000

Source: U.S. Geological Survey (2008).

Presence of fl uoride, nitrate, Iron, arsenic, total hardness and a few toxic metal ions determine salinity levels in groundwater. In India, saline groundwater is found in many states, particularly in the arid and semi-arid regions of Rajasthan, Haryana, Punjab and Gujarat, and to a lesser extent in Uttar Pradesh, Delhi, Madhya Pradesh, Maharashtra, Karnataka, Bihar and Tamil Nadu. In India, about 200,000 sq. km area has been estimated to be affected by saline water (CGWB 2008a).

This chapter focuses on an intervention piloted by S M Sehgal Foundation in Karheda, a village in Mewat district, which adopted an innovative model of roof water harvesting (RWH). This model addresses the issues of groundwater salinity as well as provision of safe drinking water through creation of fresh groundwater pockets within saline aquifers. The model promotes bio-sand fi lters to mitigate biological contamination. The chapter underscores the uniqueness of this cost-effective, replicable, sustainable and almost maintenance-free approach.

PROFILE OF MEWAT

Mewat district, with a population of 1.2 million, has been carved out of Gurgaon and Faridabad, two satellite districts of Haryana bordering Delhi, India’s capital in 2005. Compared to most districts


in the state, Mewat lags behind on several socioeconomic indicators (Table 2). For instance, female literacy rate is as low as 31 per cent. Similarly, access to improved water and sanitation is very poor.

Table 10.2: Socio-economic Profi le of Mewat and Haryana

Indicators

Percentage

Mewat Haryana

Total literacy rate 51.8 73.4Female literacy rate 31.3 55.7Households with below poverty line (BPL) card 24.6 12.4Households with access to toilets 12 56.2Households with access to piped water 31.6 61Households owning agricultural land 57 40.3Households owning irrigated land 35 38Households’ standard of living Low 67.3 17.4

Medium 24.4 39.6High 8.3 43

Source: IIPS (2007, 2009), MDA (2009), RGI (2001).

CONSEQUENCES OF SALINITY IN GROUNDWATER

Certain heavy metals found in groundwater such as Arsenic, Cadmium, Copper, Mercury and Lead are toxic to humans and wild-life. According to the International Agency for Research on Cancer (IARC), prolonged consumption of drinking water containing arsenic at levels close to or higher than the established guideline value of 0.025 mg/l increases the risk of skin cancer and tumors of the bladder, kidney, liver and lung (Pollution Probe 2004). Salinity in groundwater also causes limits to use of water and can also enhance some kinds of corrosion and scaling. It also reduces the choice of technologies to be used for treatment such as ion-exchange resins (Table 10.3).

Water salinity also affects agricultural productivity directly and indirectly. Salinity decreases the permeability of the soil as the surface becomes more crusted and compacted under such conditions. Therefore, low moisture availability in the root zone affects the plant growth. Certain ions in saline waters can be specifi cally toxic to the plants, if present in excessive concentrations or proportions. Of particular


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concern are Sodium, chloride and Boron. Thus, the plant population and diversity is highly affected due to salinity (Rhoades et al. 1992).

Semi-arid regions are most vulnerable to the adverse effects of groundwater salinity since surface water resources are scarce and highly unreliable here due to low rainfall (200–500 mm). Thus, groundwater tends to be the primary source of water. Increasing demands on limited water availability leads to fast-depleting aquifers. It is often observed that groundwater salinity increases with depth. Thus, fast depletion of the groundwater further increases salinity.

DISTRIBUTION OF SALINE WATER IN HARYANA

The south–western part of Haryana faces acute salinity in groundwater. At some places here salinity is so high that salt can be manufactured by solar evaporation. High salinity is one of the major groundwater quality problems in these areas (Figure 10.1). More than 30 per cent of the area in the districts of Gurgaon, Bhiwani, Rohtak, Kaithal, Mahindergarh, Mewat and Sonepat has saline groundwater (Table 10.4).

However, of these districts, Mewat is a case in point as far as groundwater salinity and fl uoride contamination are concerned. Mewat suffers from acute water scarcity and lacks good quality water as it is underlined with saline groundwater aquifers. Out of 503 villages in Mewat, only 61 have fresh groundwater; the rest have saline groundwater (SANDRP 2004). In these villages, the high salinity content and constant rise in groundwater table has led to deteriora-tion in agricultural productivity (Tanwar and Kruseman 1985). The average annual rainfall is just 480 mm spread over 31 days.

In this district, fresh groundwater is available only in a few small pockets, usually located at the foot of Aravalis having high ground gradient. Aravalis are a range of mountains in western India running approximately 800 km from northeast to southwest across Rajasthan, Haryana and Gujarat. Here, the soil is sandy and highly permeable. However, run-off concentration time is very limited because of high ground gradient. Consequently, recharging of fresh groundwater pockets is minimal and surface water is sparse. Moreover, surrounding villages depend on these pockets for freshwater. Karheda exemplifi es

Water Quality and Human Health 205Fi

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this situation, where groundwater is highly saline and the erratic public water supply from an adjoining village 4 km away is the only source of water.

To address this problem in Mewat, the state government launched the Rajiv Gandhi Drinking Water Supply Augmentation Scheme in 2005. The scheme is a mix of Ranney Well and Tube Well tech-nologies. Ranney wells are being installed in the vicinity of Yamuna river where recharging is considered to be high. Yamuna passes through Haryana and becomes a perennial drain rather than a river by the time it reaches Delhi as it carries industrial effl uents and domestic sewage. Inevitably, the highly polluted Yamuna water recharging the aquifer increases the concentrations of dissolved chemical pollutants in groundwater. Moreover, in this scheme there is no mechanism for monitoring water quality.

Tubewells are being installed in areas with fresh groundwater pockets. The tubewell technology, however, is not sustainable in the long term as the groundwater table is depleting fast and quality is deteriorating. This project is underway and in the absence of some effi cient arrangements for recharging aquifers, the scheme does not hold much promise for providing safe drinking water.

SITUATION ANALYSIS OF KARHEDA

Karheda, with 375 households and a population of 2,400, falls in the Nagina block of Mewat (Figure 10.2). The groundwater situation in this block is very grim, where only 11 out of 63 villages have fresh groundwater and the rest have saline water.

In 2005, we conducted a preliminary survey which revealed the groundwater was just 7 feet below the ground but highly saline and

Table 10.4: Salinity and Fluoride Affected Districts in Haryana

Contaminants Districts affected in partsSalinity Sonepat, Rohtak, Hissar, Sirsa, Faridabad*, Jind, Gurgaon∗,

Bhiwani, MahendragarhFluoride Rohtak, Jind, Hissar, Bhiwani, Mahendragarh, Faridabad

Source: CGWB (2008b).∗Mewat was recently carved out of Faridabad and Gurgaon

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unfi t for human and animal consumption or even irrigation. We further conducted a chemical analysis of the groundwater and pub-lic water supply in Karheda to compare the quality of water from both the sources with desirable limits according to Indian standards (Table 10.5).

Table 10.5: Chemical Contaminants in Groundwater and Public Water Supply, 2005

Sl No. Characteristics

Desirable Limitsas per Indian Standards∗

Local Groundwater

Public SupplyWater

1 pH value 6.5 to 8.5 7.4 82 Total hardness mg/l 300 7702 4003 Iron mg/l 0.3 0.6 14 Chlorides mg/l 250 9792 2695 Fluoride mg/l 1.0 2.5 1.56 Dissolved Solids mg/l 500 30230 7107 Magnesium mg/l 30 1273 298 Calcium mg/l 75 958 1119 Sulphate mg/l 200 6972 61

10 Nitrate mg/l 45 1626 13511 Cadmium mg/l 0.01 0.07 <0.0112 Lead mg/l 0.05 0.4 <0.0113 Alkalinity mg/l 200 353 19014 Most Probable Number

(MPN) Coli form/100 ml10 7 278

Source: S M Sehgal Foundation (2005).

These results suggest that chemical contaminants in the ground-water in Karheda far exceed the desirable limits. It is interesting to note that with TDS levels of 30,230, the groundwater in Karheda is as saline as sea water. Chloride, Lead, sulfates, nitrates, Magnesium and Calcium levels are also higher than the desired levels. Even the public water supply fails on several standards. For instance, Iron, chlorides, nitrates and Calcium levels in the water, and the total hardness, are higher than the permissible levels.

Shallow groundwater table, coupled with high salinity, impacted the socioeconomic conditions in Karheda. In this village, more than


three-fourths of the work force is engaged in agriculture-related activities and more than 56 per cent of the households own agricul-tural land. However, salinity in the groundwater has adversely affected agricultural productivity by deteriorating soil quality which in turn limited the choice of crops that could be grown in the village. The domestic water demands of Karheda inhabitants were met by a public water supply system originating from Ghagas, a village 4 km away.

Haryana lacks clear policies on groundwater extraction rights. In such a scenario, we found that some economically well-off farmers purchased small patches of land in Ghagas and installed tubewells. Water from these tubewells is pumped into agricultural lands of villages that have saline groundwater through 4–6 km long under-ground pipelines, further exacerbating the situation.

Apart from Karheda, seven other surrounding villages which have saline groundwater also depend on Ghagas for freshwater. This led to steady depletion of fresh groundwater in Ghagas. Moreover, the survey also found that the rising saline groundwater table was steadily advancing towards the fresh groundwater aquifer in Ghagas, thereby shrinking the already diminishing fresh groundwater pocket in Ghagas (Figure 10.3). Consequently, many wells that fall between Karheda and Ghagas, which had freshwater, now have saline water.

Following the preliminary survey, we carried out an in-depth situ-ation analysis of Karheda in order to get a clear understanding of the water situation in the village, including the problems with existing local groundwater, current source and its reliability. The situation analysis was also intended to work out an innovative method to create some source of potable water within Karheda. As part of this analysis, a comprehensive survey was conducted to assess the community’s behaviour regarding water usage, conservation and disposal, as well as their level of awareness on sanitation and hygiene.

A sample of 166 households out of 375 was randomly selected for the study. The respondents for the survey were women as they are usually responsible for water collection and would be able to give an accurate picture. Moreover, an in-depth focus group discussion (FGD) was also conducted with the villagers (both men and women) to get their perceptions on public water supply.


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RESULTS OF THE SURVEY

Table 10.6 presents the characteristics of the respondents in the village. In Karheda, a majority of the household heads are Muslims and are backward. Literacy levels—reading and writing in Hindi or Urdu—are moderate, and 40 per cent of the household heads are illiterate.

Table 10.6: Characteristics of the Sample Households (Sample Size=166)

Characteristics Share (percentage)

Religion Hindu Muslim Others

2871 1

Caste Scheduled caste Backward caste

1684

Education Literate Illiterate

6040

Table 10.7 presents the availability of water and sanitation facilities for households. Eighty-seven per cent of the households depend on public water supply. Of these, nearly three-fourths of the households collect water from shared stand posts located outside household premises. A majority of these households spend about 1–2 hours to fetch water every day, and about 20 per cent spend more than three hours. Sanitation facilities in Karheda are abysmal with 80 per cent of households lacking any toilet facilities (Table 10.7). On an average, a household fetches about 200 litres of water per day.

The respondents were asked who was responsible for providing water in the village. Eighty-six per cent of the respondents felt that the government or panchayat was responsible for provision of water in the village. We also collected information on the prevalence of diar-rhoea two weeks prior to the survey in all the households with children below 5 years. The prevalence of diarrhoea was recorded as reported and defi ned by the respondent. In our survey, incidence of diarrhoea was reported in 56 per cent of the households. In order to capture awareness levels, respondents were asked a series of questions regard-ing causes and ways to prevent diarrhoea. Ten per cent respondents


did not know any cause while 77 per cent mentioned ‘dirty water’ as the main reason for diarrhoea. Four per cent respondents mentioned teething as the cause, while 96 per cent mentioned unclean food, poor hygiene, open defecation and dirty hands as causes of diarrhoea.

Further, 64 per cent of the respondents felt that diarrhoea could be prevented. Of the respondents, 65 per cent mentioned the practice of rinsing their hands with water as a preventive measure. Only 12 per cent mentioned washing hands with soap as the sure way of prevent-ing the disease. Safe sanitation and clean water were mentioned by 3 and 12 per cent of the respondents respectively to prevent diarrhoea. It is interesting to note that less than one per cent of the respondents mentioned burying faeces, preparing food hygienically and treating drinking water as ways of preventing diarrhoea. Information on select hygiene practices was also collected in the survey (Table 10.8). Nearly half of the households did not purify water. Although 50 per cent households resorted to some form of purifying water such as straining with cloth, using alum or just boiling, these practices individually are insuffi cient to completely remove the pathogens from water.

The above fi ndings suggested that although awareness existed, it was limited to a few practices and there is need for increasing in-depth awareness of all possible causes and preventive measures.

Table 10.7: Water and Sanitation Facilities

Characteristics Share (Percentage)

Water source (N=166)Public water supplyOthers

8713

Location of public water supply (N=144)Within houses (individual)Outside house premises (shared)

2971

Time for fetching water from public source outside the house (N=102)

Less than 1 hr1–2 hrs2–3 hrsMore than 3 hrs

2463121

Toilet facility (N=166)YesNo

2080


Table 10.8: Hygiene Practices (Sample Size = 166)

Characteristics Share (Percentage)

Water purifying methods Not purifi ed Strain by cloth/alum/boilingWater fi lter

49501

Storage of water In uncovered containerIn covered container

1486

Keeping food coveredNoYes

496

Washing of hands after defecationNoYes

199

Washing of hands before cooking and eating foodNoYes

298

Waste water stagnation outside the householdNoYes

5446

Wearing footwearNoYes

2773

Burning or burying of waste from householdsNoYes

955

Following all hygienic practicesNoYes

982

FOCUS GROUP DISCUSSION (FGD)The results of the survey were also substantiated by in-depth FGDs with women and men in the village. The FGDs were conducted in order to fathom critical issues and problems related to water faced by them. Discussions revealed that salinity was indeed extremely high in the groundwater of Karheda. For instance, a woman said that the non-availability of freshwater and dependence on saline groundwater had several ramifi cations and impacted her household’s social, economic, political and health aspects. She said:


Saline groundwater is the main cause of our poverty. The water cannot be used for irrigating the fi elds and our crops are only rain fed. In case rains are scanty or untimely, we are not able to grow even one crop a year. Productivity is very low because the soil is also saline.

The water could not be used for bathing or washing purposes. Women reported of allergic reactions like skin rashes and lesions due to the use of saline groundwater. Further, the water could not be used for construction because the salt posed problems of effl orescence—precipitation of salts on the surface leading to decay—in the structure, reducing the life of the structure drastically. Even mud plastering, which is common across villages in India, cannot be done with this water because after drying, the salt precipitates on the surface and white powder like deposits peel off the plaster. The water is unfi t for cooking or animal consumption because of salty taste and chemical pollution. One respondent stated:

The water is so saline that we cannot make even a cup of tea with it, let alone drinking …we cannot cook ‘dal’ (lentils) because it does not soften even after boiling it for long. The utensils are left with white spots when washed with this water.

Further, women and young girls travelled for an hour (3–4 km) per trip to nearby villages to fetch water during periods of non-supply, estimated to be about 120 days a year. On an average, a household makes at least fi ve trips to collect water to meet daily requirements. As a result, most young girls are unable to attend school regularly. Another alarming and thought-provoking fi nding was that fast deple-tion and shrinking of fresh groundwater pockets have been creating unrest among the communities in Ghagas. They have started resisting water supply being channelled to other villages. On the other hand, since the villages in saline groundwater pockets have no alternative, their situation worsened every day. This led to inter-village commu-nity confl icts. For instance, Karheda is heavily dependent on water supply from Ghagas. However, in Ghagas, due to fast depletion of groundwater and steady deterioration of its quality, a union has been formed to resist water supply to Karheda and other villages.

It was found that most of the community members have limited knowledge about the concept of safe drinking water, water-borne


diseases and preventive practices. Most of them are unaware about the effects of presence of dissolved salts in the water. The commu-nity members also pointed out the presence of leaking supply lines, a potential source of contamination. It was also pointed out that most of the inhabitants had yellow and brown stains on their teeth. Some elderly people also informed that they had knee and joint pains and suspected water that has fl uoride to be the cause. The detrimental consequences on health mentioned during FGDs were further reinforced by Chowdhury’s study (2005) on health status of school children from government primary schools in seven villages of Mewat (Table 10.9).

Table 10.9: Morbidity among School Children of Mewat

DiseaseBoys

(N = 995)Girls

(N = 481)Total

(N = 1476)

Dental problems 787(79.1%)

425(88.4%)

1,400(94.9%)

ENT problems 107(10.8%)

56(11.6%)

163(11.04%)

Anaemia 102(10.3%)

60(12.5%)

162(10.9%)

Poor nutritional status 151(15.2%)

107(22.2%)

158(10.7%)

Eye and vision problems 100(10.1%)

35(7.2%)

135(9.2%)

Skin problems 56(5.6%)

24(4.9%)

81(5.5%)

Respiratory problems 18(1.8%)

8(1.7%)

26(1.8%)

Abdominal pain 21(1.4%)

5(1%)

26(1.8%)

Orthopedic problems 6(0.6%)

2(0.4%)

8(0.5%)

Source: Chowdhury (2005).

There was an urgent need to develop an innovative approach to ensure sustainable potable water source within the village, taking into account the social, economic, environmental and technical aspects


suitable to the local conditions. A crucial component of this approach was to create awareness on various aspects of water such as conserva-tion, collection, judicious use and safe disposal of waste water.

INNOVATIVE APPROACH In order to address water-related issues in Karheda, an innovative model was conceived based on the thorough understanding of the local conditions and constraints. These constraints included:

z Non-availability of reliable grid electric supplyz Financial constraints of the community to afford costlier

solutionsz Short Rainy season restricted to once a year (just 31 wet days

per year)z High levels of groundwater salinityz Low levels of skills among local communities.

Given the above constraints and weighing various technologies, resources and prevailing local conditions, three technologies were shortlisted to work out the most suitable solution for Karheda. These included:

z Reverse osmosis using local saline groundwaterz Solar desalination using local saline groundwaterz Roof Water Harvesting (RWH)

On the question of treating either saline groundwater or harvested rain water, the latter was considered a better option. Table 10.10 highlights the salient features of probable solutions.

ROOF WATER HARVESTING (RWH)Keeping in view the opportunities and constraints in Karheda, RWH seemed the most suitable option. In many rural parts of India, particu-larly in Rajasthan and Gujarat, which have similar geographical con-ditions, RWH has been a traditional practice to solve water scarcity.


Tab

le 1

0.10

: C

ompa

riso

n of

Sui

tabl

e T

echn

olog

ies

for

Kar

heda

’s W

ater

Sit

uati

on

Tec

hnol

ogie

s for

Sal

ine G

roun

dwat

erT

echn

olog

ies f

or H

arve

sted

Roof

Wat

er

Reve

rse O

smos

isSo

lar D

istill

atio

nSt

orag

eRe

char

ging

Adv

anta

ges

-Effe

ctiv

ely

rem

oves

all

type

s of

con

tam

inan

ts to

som

e ex

tent

(p

artic

les,

mic

roor

gani

sms,

collo

ids

and

diss

olve

d in

orga

nic

mat

ter)

.- R

equi

res m

inim

al

mai

nten

ance

.

-Rem

oves

a b

road

rang

e of

co

ntam

inan

ts-R

eusa

ble

Can

cre

ate

high

qua

lity

wat

er

loca

lly.

-Low

cos

t

-No

spac

e re

quire

d.

Lim

itatio

ns-H

igh

TD

S of

inpu

t-C

ost (

capi

tal,

oper

atio

n an

d m

aint

enan

ce)

-Ene

rgy

-Low

Rec

over

y-W

aste

Disp

osal

-Low

pro

duct

ivity

-S

un d

epen

dent

-Inc

onsis

tent

out

put

-Nee

d Sp

ace

-Con

tam

inan

ts w

ith lo

w

boili

ng p

oint

ca

nnot

be

rem

oved

-Hig

h co

st-N

eed

Spac

e-C

onta

min

atio

n-R

ain

depe

nden

t-R

ains

are

onc

e a

year

-Hig

hly

salin

e gr

ound

wat

er.

-Low

pot

entia

l in

shal

low

gr

ound

wat

er a

reas

.-C

onta

min

atio

n-N

o co

ntro

l ove

r un

derg

roun

d sp

read

.


Traditionally, harvested water is stored in underground tanks called Tankas. Design and storage capacity of these tanks were determined by water demand and availability of rain water. With time, owing to changes in lifestyles, the demand for water increased considerably. Consequently, bigger tanks were required with greater storage capacity but the costs are prohibitive and beyond the community’s reach. As a result, these traditional practices have reduced drastically.

Another popular traditional option for storing water underground is kund or kundi, practised in Churu district of Rajasthan. These kunds are roughly 6 metres deep and 2 metres wide tanks resting over semi-permeable or non-permeable soil strata. They are used to store the harvested rain water. The stored water remains intact as it is not exposed to light and air. The water does not percolate down because of low permeability of the strata, which is further plugged by fi ne silt coming with water (Agarwal and Narain 1997). In the context of Karheda, the traditional practice of tanka cannot be afforded by the poor community. Moreover, the geological conditions of Mewat do not permit the adoption of kund in the region, as the soil is sandy and groundwater is just seven feet below the ground.

Another option was recharging the groundwater with harvested rain water. Usually, recharging is done deep under the ground, leaving enough distance above the groundwater table, so that the recharged water is allowed to infi ltrate into the ground in order to avoid chances of its contamination. But this recharged freshwater does not remain in a consolidated mass but spreads out over a period of time ultimately to produce a thin layer of fresh groundwater over the existing saline groundwater (Figure 10.4).

Exploiting this thin layer of fresh groundwater separately is practic-ally very diffi cult because in the process of extraction it could mix with the saline groundwater. In order to exploit this harvested rain water it should form a pocket of sizeable depth rather than a thin layer. To achieve this, an innovative change to the traditional recharging method was adopted in Karheda. In the new innovative model, recharge wells were sunk to a depth lower than groundwater table (Figure 10.5). With this small change the desired freshwater pocket could be formed easily. This pocket was formed by pushing away and replacing the existing saline groundwater by harvested freshwater within the aquifer.


Figu

re 1

0.4:

Spr

ead

of F

resh

Har

vest

ed R

ain

Wat

er u

nder

the

Gro

und


Figure 10.5: Innovative Model of RWH in Karheda

When groundwater is extracted from the recharge well, the harvested freshwater from this pocket could be reached fi rst as it is pushed up by the surrounding saline groundwater.

Underlying Concept of the Model

The rain water harvested from the roof is directed deep into the ground through recharge wells. This innovation is cost-effective and replicable based on basic scientifi c principles. The scientifi c explana-tion of formation of fresh groundwater pocket within saline one is as follows:


z Density of harvested rain water is lower than that of saline groundwater. Thus when low density water comes over the higher density one, the former fl oats over the latter.

z Because of the pressure of overburden, harvested freshwater pushes the existing saline groundwater down taking its place to form a new pocket of itself within the saline aquifer.

z Further, the fl ow of freshwater under the ground, through the tiny void spaces among the soil particles is a streamlined fl ow. This results in minimal turbulence negating any stirring effect, thus preventing mixing of the harvested freshwater and existing saline water.

z The first rush of water into the void spaces flushes out chemical residues of saline groundwater, minimising chemical contamination.

z The buoyant force exerted by the surrounding saline groundwater on the harvested water keeps the harvested water pocket intact from scattering. The process of diffusion through Brownian Motion (BM) is curtailed because of limited free space available within soil voids.

z Water thus stored under the ground remains totally cut off from sunlight and air. This prevents any growth of pathogens minimising chances of further contamination.

This model, therefore, is very cost effective as it does not require any additional cost to create a storage structure. In some cases, recharging aquifers may improve the source water quality, because the subsurface has the ability to naturally decrease many chemical and biological constituents through physical, chemical, and biologi-cal processes. However, in Karheda, since the water table is shallow, there could be a potential risk of biological contamination. In order to address this issue, bio-sand fi lters were promoted along with RWH structures. A bio-sand fi lter is a concrete container, with layers of sand and gravel inside it. The sand and gravel remove dirt, bacteria, viruses and parasites and other physical and biological impurities from the water (Figure 10.6).

In a bio-sand fi lter, water is poured from the top. There is a dif-fuser plate placed just above the sand bed that absorbs the shock of the falling water. So it does not disturb the sand. Travelling slowly


Figure 10.6: Bio-sand Filter


through the sand bed, the water then passes through several layers of sand and gravel and then is pushed up through piping encased in the concrete, and out of the fi lter, for the user to collect. When water is poured from the top, the organic impurities get trapped at the surface of the sand, forming a bio layer or ‘schmutzdecke’. Four processes remove pathogens and other contaminants in this fi lter:

1. Predation: The bio layer micro-organisms eat bacteria and other pathogens found in the water.

2. Natural death: Pathogens die because there is not enough food and oxygen to sustain them all.

3. Adsorption: Viruses are adsorbed (become attached) to the sand grains. Once attached, they are metabolised by the cells or are inactivated by antiviral chemicals produced by the organisms in the fi lter. Certain organic compounds are also adsorbed to the sand and therefore removed from the water.

4. Mechanical trapping: Sediments, cysts and worms are removed from the water as they get trapped in the spaces between the sand grains. The fi lter can also remove some inorganic compounds and metals from the water when they are precipitated into solid form.

Prior to implementing the model in the entire village, this innova-tive approach was fi rst successfully demonstrated in a primary school in Karheda in 2006. The water problems in the school epitomised those that the village faced.

RWH Model in Karheda Primary School

The school catering to 200 students had an underground tank to store water from public supply, but due to poor upkeep, the unhygienic water was not used. The water supply was extremely erratic due to various reasons such as low pressure, leakages and poor maintenance of the distribution network. The daily requirement of water in the primary school was 500 litres including 200 litres for drinking, 120 litres for cooking mid-day meals and 180 litres for sanitation and other purposes. Total annual water demand works out to be about 100,000


litres (for 200 working days). In 2006, S M Sehgal Foundation established an RWH system to recharge the aquifer by passing it through a simple sand fi lter with the following objectives:

z To provide alternative source of waterz To generate awareness among the school children about

RWH so that they could spread the information among the community.

z To demonstrate the feasibility of the model and acquire a buy-in from the community.

The RWH unit was set up for a roof area of 300 square metres to capture rain water. The average annual rainfall of 500 mm would harvest 127,500 litres of water. Since July 2006, the school has been using the recharged water. The present water harvesting capacity surpasses the required amount resulting in sustainable and reliable water supply for the school.

Results

The Karheda primary school now has a ready and reliable source of potable water which was further made safe through bio-sand fi lter. Mayawati, an Anganwadi worker who is in-charge of preparation of the mid-day meal at the school, reported, ‘…now the problem of water in the school is solved with the installation of RWH and bio-sand fi lter. Now all round the year we have water suffi cient for cooking, drinking and sanitation.’

Results of water analysis in Table 10.11 indicate that the proper-ties of recharged water are better than desirable levels but show a substantial concentration of coli form. However, it should be noted that such high levels of coli form are imminent and expected in shallow groundwater given that open defecation, stagnation of waste water and composting are highly prevalent in Karheda. This issue was addressed through the promotion of bio-sand fi lters. Further testing of harvested water fi ltered through bio-sand fi lters revealed absence of coli forms.

A respondent who had adopted this model in her household reported, ‘There has been no diarrhoea in our household in the last


Tab

le 1

0.11

: C

hem

ical

Con

tam

inan

ts in

Gro

undw

ater

, Pub

lic W

ater

Sup

ply

and

Rec

harg

e W

ell

Cha

ract

erist

ics

Des

irab

le Li

mits

as p

er In

dian

Sta

ndar

dsG

roun

dwat

erPu

blic

Sup

ply

Wat

erW

ater

from

Sch

ool R

WH

Re

char

ge W

ell

pH v

alue

6.5

to 8

.57.

48

7.0

Tot

al H

ardn

ess m

g/l

300

7702

400

95Ir

on m

g/l

0.3

0.6

10.

02C

hlor

ides

mg/

l25

097

9226

939

Fluo

ride

mg/

l1.

02.

51.

50.

3D

issol

ved

Solid

s mg/

l50

030

230

710

201

Mag

nesiu

m m

g/l

3012

7329

6C

alci

um m

g/l

7595

811

128

Sulp

hate

mg/

l20

069

7261

51N

itrat

e m

g/l

4516

2613

54

Cad

miu

m m

g/l

0.01

0.07

<0.0

1<0

.01

Lead

mg/

l0.

050.

4<0

.01

<0.0

1A

lkal

inity

mg/

l20

035

319

051

MPN

col

i for

m /1

00 m

l10

727

890

0


few months ever since we adopted the RWH and bio-sand fi lter. Earlier, there were white spots in the containers used for storing water, but now there are no white spots.’

DISCUSSION AND THE WAY FORWARD

Groundwater has been an important source, particularly in the rain-fed semi-arid regions of India. The quality and availability of groundwater is not uniform across the country. In most of the semi-arid and arid areas of Punjab, Haryana, Rajasthan and Gujarat the available ground-water is saline. In the absence of other sources of water, poor quality of groundwater has not only health implications but also social, economic and political ones as well. In this context, Mewat is a case in point where fresh groundwater is limited to 61 out of 503 villages.

In Mewat, salinity and fast depletion of fresh groundwater has been a serious problem as this affects the quality of life of the inhabit-ants in more ways than one. Given that there is no policy to regulate groundwater extraction in addition to availability of free or heavily subsidised electric supply for agricultural operations, the potential for advancement of saline groundwater pockets is extremely high in the region. The severity of the water crisis in Karheda is similar to those of the overall water problems in Mewat where salinity of groundwater is as high as that found in sea water.

In this scenario, an innovative RWH model along with bio-sand fi lter was a cost-effective, sustainable and replicable solution. This innovation was targeted to address issues such as groundwater salinity, groundwater depletion, drudgery of fetching water from long dis-tances and loss of study hours due to absence of water in the school premises. Such a model was successfully demonstrated at a govern-ment primary school in Karheda. The schoolchildren, who have had fi rsthand experience of reaping the benefi ts of this model, have been spreading awareness on the effectiveness of this model. This resulted in an increase in the adoption of this model in the households not only in Karheda but also in nearby villages.

A pivotal aspect in the adoption of this model was community involvement. During the initial phases of the project demonstration at the school, concerted and consistent efforts were required to make


the community appreciate not only the gravity of the water situation but also its detrimental consequences. Once the community realised that there could be a cost-effective and reliable solution to the saline groundwater problem, they willingly came forward to adopt this model in their households. So far 24 households have adopted this model. There is also an increasing demand for adoption of this model in the surrounding villages.

The model has high potential in regions with saline groundwater and in coastal areas where sea water ingress poses a major challenge. Experiences from Karheda and its nearby villages underscore that the model is highly affordable and can be easily replicated. Replication is contingent on a strong buy-in for the model in the community and lack of awareness on water related issues as was the case in Karheda prior to the introduction of the model could pose potential challenges. It is in such a scenario that Gram Panchayats and district adminis-tration could play the role of a facilitator in promoting this model through systematic awareness generation.

Once a community is triggered to adopt this model, then the district administration as well as other stakeholders such as local non-governmental organisations (NGOs), government offi cials, schools, self-help groups (SHGs) could provide intermediation and fi nancial support and capacity building particularly on the technical details to grassroots implementers. In this way, the model can be institutionalised and can be brought to scale in those areas with saline groundwater pockets.

REFERENCES

Agarwal, A. and S. Narain. 1997. Dying Wisdom: Rise, Fall and Potential of India’s Traditional Water Harvesting System, New Dehi: Centre for Science and Environment.

CDC. 2003. ‘Lead and Drinking Water from Private Wells’, Centre for Disease Control and Prevention. Available online at http://www.cdc.gov/ncidod/dpd/healthywater/factsheets/lead.htm. Downloaded on 10 October 2008.

CGWB. 2008a. ‘Groundwater quality features of the country’, Central Groundwater Board. Available at http://cgwb.gov.in/documents/GROUND%20WATER%20QUALITY%20SCENARIO%20IN%20INDIA.pdf (accessed 15 November 2008).


CGWB. 2008b. ‘State Profi le: Groundwater Scenario’, Central Groundwater Board. Available online at http://www.cgwb.gov.in/gw_profi les/St_Haryana.htm. Downloaded on 25 November 2008.

Chowdhury, A. 2005. Unpublished. ‘A Cross-sectional Study to Determine the Health Status of School Going Children of Mewat District of Haryana’. Gurgaon: Institute of Rural Research and Development.

Department of National Health and Welfare. 1990. Nutrition Recommendations. The Report of the Scientifi c Review Committee, Department of National Health and Welfare, Government of Canada, Ottawa, Canada.

Department of Primary Industries and Fisheries. 2008. Fact Sheet. ‘Interpretation of Water Analysis for Irrigation’. Available online at http://www.fl owersqueensland.asn.au/pdf/Fact%20Sheets%20SEQ%20RWUE/Water%20Interpretation%20of%20Water%20Analysis%20Factsheet%20%20v2.pdf. Downloaded on 10 October 2008.

IIPS. 2007. ‘Fact Sheet Haryana’. International Institute for Population Sciences. Available online at http://www.nfhsindia.org/pdf/HR.pdf. Downloaded on 10 October 2008.

———. 2009. ‘District Level Household and Facility Survey, Mewat, Haryana’, International Institute for Population Sciences. Available online at http://nrhm mis.nic.in/ui/reports/dlhsiii/HARYANA/DISTRICT%20FACT%20SHEET/20_%20factsheet_%20Mewat.xls. Downloaded on 10 October 2008.

MDA. 2009. ‘Mewat at a Glance’, Mewat Development Agency. Available online at http://mda.nic.in/Mewat-Glance.htm. Downloaded on 10 October 2008.

Mukherjee, S. 2008. ‘Factors infl uencing farmers’ willingness to protect ground-water from non-point sources of pollution in the lower Bhavani river basin, Tamil Nadu, India, presented at Third Water Environment Partnership in Asia (WEPA) International Forum on Water Environmental Governance in Asia, 23–24 October 2008, Putrajaya, Malaysia.

Pollution Probe. 2004. ‘The Source Water Protection Primer, Heavy Metals’. Available online at http://www.pollutionprobe.org/Reports/swpprimer.pdf. Downloaded on 20 November 2008.

RGI. 2001. ‘Census of India’, Registrar General of India. Available online at http://www.censusindia.gov.in/Census_Data_2001/States_at_glance/State_Links/06_har.pdf. Downloaded on 10 October 2008.

Rhoades, J.D., A., Kandiah, and A.M. Mashali. 1992. ‘The Use of Saline Waters for Crop Production,’ FAO Irrigation and Drainage Paper 48. Rome: Food and Agriculture Organization.

Ros, J.P.M. and W. Sloof. 1988. Integrated Criteria Document Cadmium, Report No. 758476004, pp 158. Bilthoven: National Institute of Public Health and Environmental Protection.

SANDRP. 2004. Dams Rivers and People, 2(7–8): 32.S M Sehgal Foundation. 2007. ‘Development of Sustainable Rural Livelihood Sys-

tem in Satyamevapuram (Mewat), Haryana’, Proposal developed for National Agricultural Innovation Project, Indian Council of Agricultural Research, New Delhi.


Tanwar, B.S. and G.P. Kruseman. 1985. ‘Saline groundwater management in Haryana state, India,’ Hydrogeology in the Service of Man. Mémoires of the 18th Congress of the International Association of Hydrogeologists, Cambridge, pp 24–30.

Tariq, R.S., M.H. Shah, N. Shaheen, M. Jaffar, and A. Khalique. 2008. ‘Statistical Source Identifi cation of Metals in Groundwater Exposed to Industrial Contami-nation,’ Environmental Monitoring and Assessment, 138(1–3): 159–65.

U.S Geological Survey. 2008. ‘Saline Water’. Available online at http://ga.water.usgs.gov/edu/saline.html. Downloaded on 22 October 2008.

WHO. 1996. ‘Guidelines for Drinking-water Quality, Health Criteria and Other Supporting Information’, Geneva: World Health Organization. Available online at http:www.who.int/water_sanitation_health/dwq/2edvol2p1.pdf. Downloaded on 11 October 2008.

WHO. 2003. ‘Iron in Drinking-water Background Document for Development of WHO Guidelines for Drinking-water Quality’, Geneva: World Health Organization.

Available online at http:www.who.int/water_sanitation_health/dwq/chemicals/iron.pdf. Downloaded on 11 October 2008.

WHO. 2004. Guidelines for Drinking-water Quality: Recommendations, 3rd edn. Vol. 1, Geneva: World Health Organization. Available online at http:www.who.int/water_sanitation_health/dwq/GDWQ2004web.pdf. Downloaded on 11 October 2008.

PART IV RAPID INDUSTRIALISATION,

WATER AND HEALTH

232 Abedullah, Shahzad Kouser and Faisal Abbas

11

Wastewater Use in Vegetable Production and Its Health Impacts

A Case of Faisalabad, Pakistan

ABEDULLAH, SHAHZAD KOUSER AND FAISAL ABBAS1

INTRODUCTION

AGRICULTURE, A SECTOR that dominantly uses water, accounts for about 80 per cent of global and 95 per cent of developing countries’ water consumption. By the year 2025, global population is likely to increase to 7.9 billion, further aggravating the scarcity of water (Rosegrant et al. 2002) that threaten economic development, sus-tainable human livelihoods and environmental quality. Utilising wastewater for irrigation is one option to meet agricultural needs. The main reasons for wastewater use are highly saline groundwater, spells of drought which deplete the water table, urbanisation, nutrient value of wastewater and its reliable supply (Ensink et al. 2004).

Among different sources of wastewater, industrial and municipal wastes are major contributors (Figure 11.1). Wastewater could be quite useful if it is applied after proper treatment using advanced technolo-gies (Bahri 2008). Untreated wastewater could be cost effective when the costs of negative externalities are not included in the analysis. After taking into account the negative externalities, for example impacts on human health, it might not be feasible for agricultural use (Ensink et al. 2004). Wastewater supports livelihoods and generates consider-able value in urban and peri-urban agriculture, despite the health and

1 Dr Abedullah gratefully acknowledges the fi nancial support provided by Higher Education Commission (HEC) of Pakistan to complete the study entitled, ‘Profi t-ability of wastewater use in vegetable production with and without externalities’, on which this chapter is based.


environmental externalities associated with this practice (Scott et al. 2000, 2004).

Water that contains human waste is useful, even if untreated, but untreated industrial wastewater affects the productivity of agricultural labourers by increasing the probability of diseases (Ensink et al. 2002). International Water Management Institute (IWMI) conducted a nationwide survey in Pakistan and estimated that 32,500 hectares of land (26 per cent of the vegetable production) is directly irrigated using wastewater. A negligible proportion of wastewater is treated and no clear regulation exists for wastewater use in urban agriculture in Pakistan (Ensink et al. 2004). Irrigation of agricultural lands with wastewater increases crop production but also leads to heavy metal concentration in soil (Ensink and Van der Hoek 2008) and increases infection rate among farmers (Ramirez et al. 2002). The externalities from wastewater exploitation also affect the health of consumers using vegetables grown using untreated wastewater (Fattal et al. 1986).

Conventional cost–benefi t analysis can discourage investing scarce resources on wastewater treatment but the expected very high eco-nomic value of potential negative effects of wastewater irrigation isis

Figure 11.1: Different Sources of Urban Wastewater

Source: Van der Hoek et al. (2002).

Wastewater Use in Vegetable Production 235

totally ignored. Therefore, in the social cost-benefi t analysis these missing economic values of negative externalities or risks need to be incorporated. Present study attempts to fi ll this gap by estimating the value of forgone labour earnings and cost of medical treatment incurred due to use of untreated wastewater in vegetable production. This line of inquiry has not been explored in case of South Asia in general and particularly of Pakistan. The specifi c objective of the study is, fi rst to develop quantitative evidence to prove that in social welfare maximisation matrix use of untreated wastewater in agriculture is not economically feasible due to its negative health impacts. However, the analysis does not deal with consumption externalities under the assumption that almost all Pakistanies eat food after cooking at a very high temperature which kills majority of dangerous pathogenic micro-organisms. Second, it is rather diffi cult to identify the consumers who continuously use vegetables grown with wastewater because households purchase vegetables from different sources every day.

A comprehensive literature survey clarified that the use of wastewater affects quality of life. Thus, there is an urgent need to empirically estimate on a large scale the costs associated with the use of wastewater in urban agriculture. Most prominent costs among others include disease outbreak and adverse public health. This chapter attempts to fi ll the gap in public health domain.

EMPIRICAL MODEL AND DATA Valuing Benefi ts and Loss of Wastewater Use in Vegetable Production

Cobb–Douglas production function, besides its restrictive properties, is more popular and commonly used to study relationship in the agri-culture sector (Battese 1992, Bravo-Ureta and Pinheiro 1997, Wadud 1999). In this study Cobb–Douglas type of production function with additive error term as suggested by Just and Pope (1979) is employed, written as follows:

R A F S L P I= +α α α α α ε1 2 3 4 5 (1)


In the above equation α1, α2, α3, α4, α5 and are the partial produc-tion elasticities.

Education of the head of the household plays an important role in improving the effi ciency of resource use of the farmer even though it does not contribute directly in the production process. Hence, it is justifi able to include in the production function.

It should be noted here that revenue and all inputs are on per acre per crop basis and

R = Revenue of vegetables (Pakistan Rupees)A = Intercept termF = Active fertiliser nutrients (in kg of N, P and K)S = Quantity of vegetable seed (kg)L = Quantity of labour (hours)P = Pesticide cost (Pakistan Rupees) I = Irrigation hours (proxy for the amount of water)E = Education of head of household (proxy for management)ε = Error term

In the above equation α1, α2, α3, α4, α5 and α6 are the partial pro-duction elasticities. In contrast to other studies in production theory, revenue is considered as dependent variable because there is a drastic yield variation across vegetables. Moreover, observations for each vegetable crop are not suffi cient to run production function separately for each crop. Therefore, it is quite reasonable to merge the data for all vegetables by considering revenue as a dependent variable (Daniel 1989, Zhang

and Di Xue 2005).

A three stage non-linear estimation technique by Just and Pope (1978) is employed to obtain parameters of both water groups. The results of the third stage are used to estimate the predicted revenue by using equation (1). The variation in revenue due to difference in input use and management factors has been captured through production function and the remaining variation is purely due to difference in quality of water (wastewater or freshwater) and random shocks. Under the assumption that random shocks are similar in both wastewater and freshwater areas because selected respondents from both the areas are close to each other and operate under similar environmental and physical conditions. Thus, it is reasonable to assume that the difference


in variation of revenue of the two groups is due to water quality. The difference in predicted revenue between two groups could be referred to as the contribution or loss of wastewater use but there is also difference in costs of production. Hence, the difference of net profi ts of the two groups is referred to as the contribution or loss of wastewater use in vegetables production. The average net benefi t of wastewater (ANBw) per acre is estimated by employing equation (A1) of Annexure. The emphasis of this study is in incorporating the cost of health externalities in cost–benefi t analysis and, therefore, fi rst of all it is required to explain how the external cost of health is estimated.

Economic Value of Labour Productivity and Medical Expenditure Loss

Illnesses caused by wastewater pathogens may result in loss of potential earnings and medical costs which are evaluated by using opportunity cost principle. These losses are quantifi ed in economic terms by using the information on prevalence of disease, such as number of sick days, part-time work loss due to sickness and off work generally called restricted activity days in literature, and daily wage rate. Value of annual labour productivity loss (VALPL) due to the diseases caused by wastewater is estimated by employing equation (A2) of Annexure.

Healthcare costs and inconvenience costs of wastewater use in vegetable production should be added to obtain total costs to health. The medical costs include the cost of consultations, medication, transport, cost of continued use of medicine and protective measures to avert the future disease risk and other out of pocket expenses. Only 15 per cent of the sample is using public health facilities because of poor infrastructure there. The private treatment costs can be used as proxy—opportunity cost—for medical costs because public healthcare is highly subsidised in Pakistan. Therefore, it cannot represent the actual medical expenditure (Nishtar 2007). Another reason for using private instead of public health facilities by the majority is ineffi ciency of the public health care sector (Zaidi 2005). Value of annual medical expenditures loss (VAMEL) for both wastewater (VAMELw) and freshwater (VAMELfr) growers is calculated with the help of equation (A3) of Annexure.


Cost–Benefi t Analysis after Internalising the Cost of Externalities

Average per acre net benefi t (or loss) of wastewater use (ANBWE) after internalising the average cost of health damages or externalities (ACHDw) in vegetable production is estimated as follows.

ANBWE = ANBw – ACHDW (2)

Where, ANBw and ACHDw are respectively average net benefi t of wastewater use without internalising the health externalities and aver-age cost of health damages, or health externalities, with wastewater use in vegetable production, and are estimated by employing equations (A1) and (A4) of Annexure, respectively.

Data

Faisalabad district is the second biggest city of Punjab province after Lahore, and is called the Manchester of Pakistan due to heavy textile industry. It was selected for study as its wastewater is highly contami-nated due to its textile industry. The data was collected from a sample of 240 farmers, 120 from each group (freshwater/wastewater users) using stratifi ed random sampling method. Sampling frame consisted of list of all farmers in each stratum.

The different villages where wastewater is used for irrigation are Chakera, Judgewal, Marzipura, ABC Cinema, Liaqat Town and Chak Jummra which fall within the boundaries of Faisalabad municipality. Among these Chakera and Judgewala are the major users of waste-water compared to other villages. These villages consume almost 80 per cent of total wastewater in Faisalabad and we divided our sample among different villages accordingly. The freshwater data has been collected from Ameanpur Bangla, Lehran, Tanola, Shahbaz pur and Char Chak villages.

The questionnaire covered particulars of the farmers, farm size, area under vegetable crops, irrigation sources, production expendi-tures, yield, prices, gross and net income, land rent, and so on. The data on different kinds of sickness and number of days of sickness in a year was collected from each respondent and also from non-farm community living in the area. The probability of sickness from a


particular disease in each group is estimated by employing a set of 200 respondents (120 farmers and 80 non-farmers) in each group. The detailed expenditures on each kind of sickness are also collected from all respondents for estimating the total expenditure to get the cost of medical treatment for each illness.

RESULTS AND DISCUSSIONS

A small number of farmers (10 per cent) used farmyard manure in freshwater area while no wastewater farmer applied manure, indicat-ing that wastewater is a substitute for farmyard manure (Table 11.1). In freshwater areas farmers use signifi cantly higher level of active nutrients of Nitrogen, Phosphorus and Potassium (NPK) (84 kg per acre) compared to 40 kg in wastewater because wastewater contains high amount of nitrogen (Ensink et al. 2002). One ton of farmyard manure converted into nitrogen (N) generates 10 kg of active nutrient of Nitrogen (Ali 1996).

Based on the average market price of N if farmers would have to supply that amount of N from Urea, then they have to pay the market price for it. It clearly indicates that wastewater also works as a substitute for fertiliser and helps save Rs 2,182 per acre for growers using wastewater due to less use of chemical fertilisers. Average labour use per acre in freshwater is 131 hours compared to 141 hours in wastewater. The higher labour use is because wastewater farmers have to plant nursery for some vegetables and also practise hoeing. Furthermore, farmers face more severe problems of weeds due to untreated wastewater which require more labour. Average irrigation hours in freshwater and wastewater areas are 26 and 13 hours per acre, respectively, implying that intensity of wastewater fl ow is high compared to freshwater. Therefore, wastewater users require less time to irrigate fi elds compared to freshwater users. This helps wastewater users to reduce their costs of irrigation. Surplus availability of waste-water also results in high cropping intensity in wastewater area, but on the other hand, increases the pesticide costs due to the favourable environment for pests to grow. Mean predicted yield, after capturing the impact of different levels of input use and management factors, of vegetables in freshwater and wastewater area is 250 and 220 pallies per acre, respectively.

240 Abedullah, Shahzad Kouser and Faisal AbbasT

able

11.

1:

Mea

n V

alue

s of

Inp

ut–O

utpu

t Qua

ntit

ies

per

Acr

e (F

resh

wat

er a

nd W

aste

wat

er)

Cat

egor

yYi

eld (P

allie

s)∗Fe

rtili

ser (

kg)

Seed

(kg)

Pest

Cos

t (`)

Labo

ur (h

rs)

Irri

gatio

n (h

rs)

Cau

lifl o

wer

180

431

467

142

12

Lady

’s fi n

ger

6651

989

011

416

Tom

ato

413

551

1633

152

13

Tin

da g

ourd

6029

1050

215

015

Spin

ach

258

4332

1250

117

15

Gar

lic41

5516

125

101

14

Cor

iand

er50

3844

250

8923

Cau

lifl o

wer

216

891

1268

139

24

Lady

’s fi n

ger

7972

1711

9613

831

Tom

ato

458

131

216

5014

334

Pota

to17

415

096

416

1414

323

Rad

ish11

775

278

812

822

Car

rot

9682

682

012

822

Pea

496

9433

1283

128

19

Pum

pkin

152

602

1254

121

35

Bitt

er g

ourd

5578

277

514

533

Chi

lli35

951

865

146

33

Min

t40

920

833

144

46

∗ One

Pal

ly =

35

kg


PRODUCTION FUNCTION ANALYSIS RESULTS

Heteroskedasticity, if present in cross-sectional data, generates asymp-totically ineffi cient coeffi cients (Green 2003, Just and Pope 1979, Wooldridge 2003). A variety of tests are available. In this study, however, the Breusch–Pagan test, was applied due to reasons cited in (Breusch and Pagan 1979 and Kmenta 1986). The test is based on sample data that if the hypothesis of homoscedasticity is true, the ordinary least squares estimates of the regression coeffi cients should not differ signifi cantly from the maximum likelihood estimates that allow the possible heteroskedasticity (Breusch and Pagan 1979).

The null hypothesis of homoscedasticity is rejected at even one per cent level, suggesting the presence of heteroskedasticity in the data. To attain asymptotically effi cient coeffi cients, three stage estimation technique developed by Just and Pope (1979) is employed indepen-dently for both groups to establish the input–output relationship as defi ned in equation (1) and results are reported below (Table 11.2). In three stage estimation technique the value of multiple R2 is improved from 19 and 40 in the fi rst stage to 46 and 65 in the third stage for both groups, respectively.

The coeffi cient of fertiliser nutrients (NPK) is positive and highly signifi cant but the size of this coeffi cient in wastewater area is smaller than that in freshwater area, indicating that response of fertiliser in wastewater area is lower than that in freshwater area, because waste-water contains 39 per cent more nitrogen than the recommended level set by World Health Organization (WHO) (Ensink et al. 2002, GoP 1997). But farmers add more nutrients (1–2 urea bags per acre). Hence it contributes in reducing revenue of wastewater relative to freshwater. The negative coeffi cient of pesticide cost in wastewater is mainly due to high level of pesticide use by wastewater users that is approximately double (Rs. 1,053) compared to (Rs. 578) freshwater users due to conducive environment for insects.

The coeffi cient of labour is positive in freshwater area but nega-tive and insignifi cant in wastewater area, implying that additional labour in hoeing, seed bed preparation and so on in freshwater area generates revenue but the situation is reverse in wastewater area. The reason is that wastewater crops require less labour because of less


able

11.

2:

Pro

duct

ion

Func

tion

Est

imat

es fo

r Fr

eshw

ater

and

Was

tew

ater

per

Acr

e

Var

iabl

es

Was

tew

ater

Sta

ges

Fres

hwat

er S

tage

s

1st

2nd

3rd

1st

2nd

3rd

Inte

rcep

t15

496.

97∗

(1.5

3)10

.27∗

∗∗(4

.66)

16.8

5∗∗

(2.2

1)21

972.

40∗

(1.5

4)7.

05∗∗

∗(3

.26)

3.65

∗(1

.65)

Fert

ilise

r0.

002ns

(0.2

0)–0

.02ns

(–0.

50)

0.05

∗∗(1

.98)

0.06

ns

(1.3

7)–0

.04ns

(–0.

61)

0.15

∗∗∗

(4.5

8)Se

ed–0

.17∗

∗∗(–

5.06

)–0

.15∗

∗∗(–

3.83

)0.

12∗∗

∗(2

.66)

0.11

∗∗∗

(9.8

8)–0

.04ns

(–0.

82)

0.11

∗∗∗

(7.4

8)Pe

stic

ide

cost

0.00

1ns

(0.1

5)–0

.001

ns

(–0.

07)

–0.1

4∗∗∗

(–8.

64)

0.01

∗∗(1

.56)

0.11

∗∗∗

(4.6

7)0.

02∗∗

(1.8

7)La

bour

0.

14ns

(1.1

3)–0

.28ns

(0.6

6)–0

.05n

s(–

1.32

)–0

.001

ns

(–0.

008)

0.38

ns

(0.8

3)0.

04∗∗

(2.3

7)Ir

rigat

ion

hour

s0.

09ns

(0.7

1)0.

11ns

(0.2

4)–0

.14∗

(–1.

67)

0.05

ns

(0.8

7)–0

.14ns

(–0.

74)

0.19

∗∗∗

(3.4

1)Ed

ucat

ion

0.00

1ns

(0.3

0)0.

01ns

(0.3

9)0.

03∗∗

(1.7

7)–0

.002

∗∗(–

0.31

)0.

00ns

(0.0

2)0.

05∗∗

∗(5

.24)

R2

0.19

0.11

0.46

0.40

0.16

0.65

Adj

-R2

0.16

0.08

0.43

0.38

0.12

0.59

Not

e: Fi

gure

s in

pare

nthe

ses a

re t-

stat

istic

s

∗∗∗ ,

∗∗ ,

∗sig

nifi c

ant a

t 1%

, 5%

and

10%

ns

not

sign

ifi ca

nt


irrigation hours but they are already applying 8 per cent more labour than freshwater users. High amount of labour use might be making the coeffi cient negative.

Similarly, the coeffi cient of irrigation hours is signifi cant in both wastewater and freshwater areas but with negative and positive signs respectively, implying that revenue would decrease with increase in irrigation hours in wastewater area. One reason could be of using more water due to fi xed cost per season, and second, wastewater is contami-nated with poisonous chemicals emanating from different industries. Moreover, it is untreated. This implies that wastewater irrigation increases the toxic chemicals in soil which adversely affect the plant growth and leads to decline in revenue through yield. The coeffi cient of education is positive and signifi cant in both groups according to a priori expectations, implying that investment on education could help enhance the productivity.

COST–BENEFIT ANALYSIS WITHOUT EXTERNALITIES

Costs and benefi ts of vegetable production in both groups are esti-mated by equation (A1) in the Annexure and Table 11.3 where differ-ences are highlighted. The gross predicted revenue (after capturing the effect of difference in input use, soil characteristic, and management factors and so on) is low in wastewater area compared to freshwater area. The low average predicted revenue clearly depicts that untreated wastewater has negative impact on vegetable production in the long run. The impact of differences in input level and management has been captured through production function in both groups and the remaining variation in predicted gross revenue is referred to the dif-ference in quality of water which affects the soil fertility. Hence low average predicted revenue in wastewater area could be due to soil fertility loss which takes place in the study area because of irrigation with wastewater since the past 80 years (Ensink and Van der Hoek 2008). The prices of comparable vegetables in both groups are not signifi cantly different from each other. Therefore, it is impossible for consumers to differentiate between vegetables grown with wastewater or freshwater. Fertiliser is one of the major contributors in cash cost, which is three times higher in freshwater than wastewater. The low


Table 11.3: Cost–Benefi t Analysis for Wastewater and Freshwater Growers (in US$ per acre)

Classifi cation Wastewater Freshwater

a. Gross returns Cash costs 564 625∗Pesticide 18 9∗

Fertiliser 17 54∗Seed – 52Labour∗∗ 69 57∗

Land preparation 69 67

Irrigation 10 42∗

Total183(74)

281∗(89)

Non-cash costsSeed 26 –Labour 38 37

Total64

(26)37∗

(11)

Total labour cost∗∗ 107(43)

94∗(30)

b. Total cost 247 317∗

Net benefi t= a − b 317 308∗

Net benefi t per unit of cash cost 1.7 1.1

Note: Figures in parentheses are costs of total vegetable production in percentage.

∗ Values are signifi cantly different from each other for two groups. ∗∗ includes weeding cost (manual)

cost of fertiliser in wastewater area is due to the fact that wastewater contains high amount of nutrients (NPK).

The total cost of hired and family labour for wastewater is higher than that for freshwater due to intensive use of labour for weeding since germination of weeds in wastewater area is higher. Moreover, high amount of pesticide use in wastewater area requires more labour hours than that for freshwater area. The contribution of labour cost in total cost of production is 43 and 30 per cent in both groups respectively, indicating that vegetable production is a labour intensive enterprise and is relatively more in wastewater. This suggests that the


expansion of wastewater use in vegetable production could expand the absorption of labour in the agriculture sector. The cost of irrigation in freshwater farming is higher compared to wastewater. Availability of less canal water forces farmers to supplement irrigation with tubewell water which costs higher due to high diesel prices.

Cash cost in freshwater area contributes 89 per cent of total cost of production. But in wastewater area it is only 74 per cent. However, non-cash cost is higher in wastewater area (US$ 64) than freshwater area (US$ 37) but not as much as cash costs, implying that farmers depend more on market-based resources for vegetable production than available at home.

The net benefi t is 3 per cent higher in wastewater area compared to freshwater area. The rate of return per US dollar of cash cost is estimated after dividing net benefi ts by total cash costs to obtain the rate of return on cash investment in vegetable production in both groups. The rate of return from cash investment is higher (1.7 per cent) in wastewater area than in freshwater area (1.1 per cent) because of lower cash cost incurred in wastewater area. Net benefi t or value of wastewater use is estimated by employing equation (A1) (Annex) which is US$ 9.35 per acre and for the whole wastewater area (5,283 acres) it is US$ 49,396. These values represent the total net benefi t of wastewater use for the whole study area before internalising the cost of externalities in vegetable production.

ECONOMIC VALUE OF EXTERNALITIES

This study considers the health externalities of wastewater use, that is labour productivity loss and medical expenditure incurred on dif-ferent kinds of sicknesses. The detailed procedure of estimation and fi nal results are discussed below.

Probability of Different Diseases

Untreated wastewater is being used in wastewater study areas, espe-cially in Chakera, for irrigation purpose which contains high concen-tration of helminthes eggs, faecal coli form of bacteria and intestinal nematode (hookworm, Ascaris lumbricoides and Trichuris truchiura)


that far exceeded the WHO guidelines (Ensink et al. 2002). This poses a high potential health risk to both the farmers and consumers. Due to limited resources the blood sample of the farmers are not collected to see the effect of different pathogens on health. To get information on different kinds of sicknesses over the year, it requires several tests of each sample farmer in a year which was not possible due to limited resources and time. Therefore, farmers in each group were asked to recall about the frequency and the kind of sicknesses. The probability distribution for each kind of sickness in both groups is estimated by applying the sparse data rule (Anderson et al. 1977) on 120 farmers in each group (Table 11.4).

The wastewater users are found to have signifi cantly higher preva-lence of Hepatitis, vomiting, stomach ache, skin allergy, Cholera, Diarrhoea, Typhoid and Dysentery relative to freshwater. This implies that probability of existence and affect of pathogens are signifi cantly higher among wastewater farmers and workers compared to those use freshwater. Thus, wastewater farmers are at greater risk of contracting disease, simply because they have intensive contact with wastewater as they do most of the fi eld works manually and barefooted (Shuval et al. 1986, Blumenthal et al. 2000). Wastewater, through leaching down is also polluting the ground water with heavy metals, nitrate and organic matter (Kretschmer et al. 2002). Diseases like Typhoid and Dysentery appears in farmers due to drinking unsafe ground water. However, probability of fever and cold was almost the same in both areas because these sicknesses do not necessarily appear due to wastewater use.

Labour Productivity Loss

By employing the probability and opportunity cost principle, using market wage rate, in equation (A2) of Annexure, the value of loss of potential earnings or labour productivity loss due to each kind of sickness is estimated for both groups (Table 11.4). In wastewater area labour productivity loss due to stomach ache and Hepatitis is found to be the highest, US$ 3.3 million and 2.8 million, respectively. The farmers during their farming activities remain in contact with contaminated soil which generates a high loss of potential earnings


Tab

le 1

1.4:

A

nnua

l Lab

our

Pro

duct

ivit

y Lo

ss (

mon

etar

y te

rms)

in W

aste

wat

er a

nd F

resh

wat

er A

reas

. Val

ues

in p

aren

thes

is a

re

in U

S do

llar

Dise

ase

Was

tew

ater

Fres

hwat

er

Prob

abili

tyAv

erag

e Day

s of

Sic

knes

s

Labo

ur

Prod

uctiv

ity L

oss

(Rs)

Prob

abili

tyAv

erag

e Day

s of

Sic

knes

s

Labo

ur

Prod

uctiv

ity L

oss

(Rs)

Hep

atiti

s0.

1219

116

7,18

5,10

0(2

,786

,418

)0.

1260

52,4

01,3

00(8

73,3

55)

Vom

iting

0.05

262

3,82

5(1

0,39

7)–

––

Stom

ach

ache

0.15

177

198,

688,

260

(3,3

11,4

71)

0.15

44,

331,

128

(72,

185)

Skin

alle

rgy

0.22

3454

,958

,983

(915

,983

)–

––

Cho

lera

0.03

61,

060,

503

(17,

675)

––

–

(Tab

le 11

.4 co

ntin

ued

)


Dise

ase

Was

tew

ater

Fres

hwat

er

Prob

abili

tyAv

erag

e Day

s of

Sic

knes

s

Labo

ur

Prod

uctiv

ity L

oss

(Rs)

Prob

abili

tyAv

erag

e Day

s of

Sic

knes

s

Labo

ur

Prod

uctiv

ity L

oss

(Rs)

Dia

rrho

ea0.

046

1,80

9,09

3(3

0,15

2)–

––

Typ

hoid

0.03

7714

,347

,975

(239

,133

)–

––

Dys

ente

ry0.

135

5,30

2,51

3(8

8,37

5)-–

––

Feve

r0.

306

14,0

36,0

63(2

33,9

34)

0.30

510

,969

,723

(182

,829

)

Col

d0.

1811

14,9

71,8

00(2

49,5

30)

0.18

45,

676,

808

(94,

613)

Tot

al–

515

472,

984,

115

(7,8

83,0

69)

–73

73,3

78,9

58(1

,222

,983

)

(Tab

le 11

.4 co

ntin

ued

)


due to skin allergy. Labour productivity loss due to Typhoid fever is US$ 0.24 million which is caused by bacterial pathogen (Salmonella typhi) present in wastewater (Shuval 1993). Cholera, a severe form of Diarrhoea is also a source of labour productivity loss equal to US$ 0.02 million. Total annual labour productivity loss due to different kinds of sicknesses is US$7.9 and 1.2 million in wastewater and freshwater areas, respectively, and the difference in labour productivity loss is US$ 6.7 million which can be referred to loss due to wastewater use.

Financial Loss in Medical Expenditures

On the one hand wastewater use causes diseases which affect productiv-ity and on the other hand the treatment of such diseases requires heavy expenditures. This means farmers have to bear the cost of medicines and it leads to welfare loss to the society. The data on medical expen-ditures is collected from the diseased farmers. The loss of money in terms of medical expenses is estimated by using equation (A3) of the Annexure. In wastewater area, medical expenditures for Hepatitis are the highest, US$ 0.6 million, followed by expenditure on stomach ache, US$ 0.3 million (Table 11.5).

The total medical expenditures are US$ 1.2 million in wastewater area and US$ 0.7 million in freshwater area. The additional expen-ditures on medicines due to wastewater use are US$ 0.6 million. Not a single case of death is found in the study area due to wastewater irrigation. Therefore, economic value of mortality is not evaluated.

Cost–Benefi t Analysis after Internalising the Externalities

Average cost of health damage (ACHDw), net labour Productivity loss (NLPLw), net medical expenditure loss (NMELw) and average net ben-efi t of wastewater after internalising the cost of externalities (ANBWE) in vegetable production are estimated by implying equations (A4), (A5) and (A6) of the Annexure, respectively. Before incorporating the values of these negative externalities, net benefi t or value of wastewater use is US$ 9.4 per acre per crop (Table 11.6) and US$ 0.01 million (=9.4∗741) for the whole study area in one crop season under the assumption that vegetables are grown in the entire study area.


able

11.

5:

Ann

ual M

edic

al E

xpen

ditu

re L

oss

in M

onet

ary

Ter

ms

in W

aste

wat

er a

nd F

resh

wat

er A

reas

Dise

ase

Was

tew

ater

(W)

Fres

hwat

er (F

)W

−F

Med

ical

Exp

endi

ture

∗(P

ak. R

upee

s)M

edic

al E

xpen

ditu

res

(US$

)∗∗

Med

ical

Exp

endi

ture

s (P

ak. R

upee

s)M

edic

al E

xpen

ditu

res

(US$

)N

et E

xpen

ditu

re

Loss

(US$

)

Hep

atiti

s36

,610

,210

610,

170

30,8

58,5

4351

4,30

995

861

Vom

iting

56,1

4493

6–

–93

6

Stom

ach

ache

18,7

27,2

2731

2,12

01,

577,

386

26,2

9028

5830

Skin

alle

rgy

1,78

6,21

929

,770

––

2977

0C

hole

ra1,

097,

932

18,2

99–

–18

299

Dia

rrho

ea29

5,27

74,

921

––

4921

Typ

hoid

3,60

7,78

860

,130

––

6013

0D

ysen

tery

1,19

5,66

519

,928

––

1992

8Fe

ver

5,61

6,50

493

,608

5,44

1,67

390

,695

2913

Col

d3,

256,

367

54,2

7387

3,35

514

,556

3971

7

Tot

al72

,249

,332

1,20

4,15

638

,750

,958

645,

849

5583

05

∗ Med

ical

exp

endi

ture

s inc

lude

cos

t of m

edic

ine,

con

sulta

tion,

pre

vent

ion

and

tran

spor

t.

∗∗1

US$

= R

s 60

in 2

007


Table 11.6: Cost–Benefi t Analysis Before and After Internalising Cost of Externalities

Category

Cost and benefi t (US$ per acre

per crop)

Cost and benefi t for the whole wastewater

area of 741 acre (US$ per crop)

Net labour productivity loss (NLPLw) 2,247 1,665,022

Net medical expenditure loss (NMELw) 188 139,576

Cost of health damage (CHDw) 2,435 1,804,598

Net benefi t of wastewater use before internalising the cost of externalities

9.4 6,965

Net/Social benefi t of wastewater use after internalising the cost of externalities

–2426 –1,797,929

NLPLw per acre per crop (forgone labour earnings) and NMELw for the treatment of untreated wastewater diseases amount to US$ 2247 and US$ 188, respectively, for vegetables production. Total external cost or cost of health damages (labour productivity loss + medical expenditure loss) due to untreated wastewater use is US$ 1.8 million per crop season for the whole study area (741 acre) and US$ 2,435 per acre per crop season. The net loss after internalising the cost of externalities is US$ 2,426 per acre per crop season and US$ 1.8 million for the whole study area (Table 11.6), implying that huge loss occurs due to wastewater use. Under the assumption that similar conditions prevail for all the four vegetable crops grown in a year in wastewater area, net loss of wastewater after internalising the cost of externalities amount to US$ 7.2 million annually for the whole study area (741 acre) and US$ 9,705 per acre annually. In order to increase the reliability of the results it is preferable to conduct future research by employing yearly data for all four crops.

CONCLUSION AND POLICY SUGGESTIONS The major aim of this chapter is to evaluate the impact on farmer’s health due to the use of untreated wastewater in vegetables


production in peri-urban areas of Faisalabad, Pakistan. For this pur-pose cost–benefi t analysis was conducted with and without health externality. Before incorporating the cost of health externality, the benefi ts of wastewater irrigation appeared greater than freshwater, which encouraged the farmers to grow more profi table crops, and have a higher cropping intensity, while the nutrient value of wastewater led to large savings in chemical fertiliser cost. Nevertheless, the adverse consequences appeared quite drastic. Irrigation with untreated waste-water adversely affected the poor vegetable growers by lowering their labour productivity, increasing their medical expenditures and declin-ing their yield due to heavy metal accumulation in soil. Therefore, after internalising these external costs, the cost of vegetable production in wastewater area signifi cantly increased compared to freshwater area; indicating that vegetables production with untreated wastewater is eco-nomically not feasible. Poor farmers are not well aware of the cause of diseases and external cost of wastewater use, because they are much concerned about the profi tability in the short run. On the other hand policymakers are not concerned about such microlevel issues in underdeveloped countries.

Therefore, the need for such type of research has increased in developing countries like Pakistan where environmental legislation is either non-existent or quite ineffective. However, to avoid the adverse impacts of wastewater use on poor farmers the possible policy options are : (a) ‘Polluters pay’ principle should be put into place by involv-ing all stakeholders. Government can levy tax on industrialists for releasing untreated wastewater. According to welfare maximisation approach, the installation of treatment plant by collecting money from industrialists through taxation seems to be the most feasible and practically viable option. (b) Another possible option for the government is to increase the number of dispensaries and hospitals in the peri-urban areas. (c) Nevertheless, the moral and ethical con-sideration by the growers themselves will positively add to reduce the disease burden and, therefore, to avoid economic and social loss. (d ) The future research should focus on internalising the external effects of wastewater use at the consumer level. (e) Moreover, in order to improve the accuracy of results, the probability of different diseases can be estimated through blood samples.


ANNEXURE

Average net benefi t of wastewater (ANBw) use per acre without externalities is estimated by the following equation:

ANB ANPV ANPV

C N C M

w w f

wi wii

N

f j f jj

R R

= −

= −⎛

⎝⎜⎜

⎞

⎠⎟⎟

− −= =∑(

.)/ (

.)/

1 1

NN

∑⎛

⎝⎜⎜

⎞

⎠⎟⎟

⎡

⎣

⎢⎢ (A1)

where,ANPV = Average per acre net profi t of vegetables for wastewater and fresh

water users

R = Per acre predicted revenue, obtained by using equation 1, of i-th or j-th farmer with wastewater and fresh water use, respectively.

C = Per acre total cost of vegetables production—cost of inputs for waste/fresh water users—) of i-th or j-th farmer, respectively. The subscripts ‘N’ and ‘M’ represent the total number of observations in each group and ‘w’ and ‘f’ stands for wastewater and freshwater, respectively. The total cost of production in wastewater / freshwater is estimated as below:

Cwi = Cash cost + Non-cash cost = (seed cost + fertilizer cost + irrigation cost with wastewater or freshwater + pesticide cost + labour cost + land preparation cost)i + (family labour cost)i

If home-produced seed is used then seed cost is included in non-cash cost.

The value of annual labour productivity loss of unemployed and underem-ployed sick individuals can be estimated by using equation given below:

VALPL = (SD∗WR∗Prob∗TP)p + .........+(SD∗WR∗Prob∗TP)Q (A2)

where,

SD = Average number of sick daysWR = Average wage rate in the study area Prob = Probability of getting P-th diseaseTP = Total population in study areaSubscripts ‘P’ and ‘Q’ are the total number of diseases attributed to wastewater use, that is from P = 1 to Q.


Value of annual medical expenditures loss (VAMEL) for both wastewater (VAMELw) and freshwater (VAMELfr) growers can be estimated indepen-dently by employing the following equation:

VAMEL = (CC + MC + TC + PC + OC )R (Prob∗TP)R + ... +

(CC + MC + TC + PC + OC )S (Prob∗TP)S (A3)

Where, subscripts ‘R’ and ‘S’ are the number of diseases attributed to waste-water use, that is R = 1, 2…… S

CC and MC = Average costs of consultation and medicineTC and PC = Average costs of transport and preventiveOC = Average of other costsProb = Probability of being affected by a certain disease

Per acre per crop average cost of health damage (ACHD) due to wastewater use in vegetables production is estimated as follows:

ACHDw = (NLPLw + NMELw)/Total area in the sample (A4)

where, NLPLw, NMELw are per crop net labour productivity loss and net medical

expenditure loss, respectively, due to wastewater use in vegetable production. NLPLw is estimated as follows:

NLPLw = [(VALPLw/4) – (VALPLf /3) (A5)

where, VALPLw and VALPLf are values of labour productivity loss in wastewater

and freshwater areas, respectively, and are estimated independently by employing equation (A2). On an average, farmers grow four vegetable crops in wastewater area and three in freshwater area annually. Therefore we have divided VALPL of wastewater and freshwater areas by four and three, respec-tively, because these costs are estimated on per annum basis but our crop productivity analysis is only for one crop season. That is why, it is important to maintain the same period of analysis in production and externalities. Similarly, net medical expenditure loss (NMELw) in one crop season due to wastewater use in vegetables production is estimated as below;

NMELw = [(VAMELw/4) – (VAMELf /3) (A6)


where,VAMELw and VAMELf are values of medical expenditures in wastewater

and freshwater areas, respectively, and are estimated by equation (A3).

REFERENCES

Ali, M. 1996. ‘Quantifying the Socio-Economic Determinants of Sustainable Crop Production: An Application to Wheat Cultivation in the Tarai of Nepal’. Agricultural Economics 14(1): 45–60.

Anderson, J.R., J.L. Dillon, and J.B. Hardaker. 1977. Agricultural Decision Analysis. Ames, Iowa: Iowa State University Press.

Bahri, A. 2008. ‘Water Woes: No Single Magic Bullet Can Solve the Developing World’s Water Problems’. Nature, 456: 39.

Battese, G.E. 1992. ‘Frontier Production Functions and Technical Effi ciency: A Survey of Empirical Applications in Agricultural Economics’. Agricultural Economics 7(3–4): 185–208.

Blumenthal, U.J., A. Peasye, G. Ruiz-Palacios, and D.D. Mara. 2000. ‘Guide-lines for Wastewater Reuse in Agriculture and Aquaculture: Recommended Revisions Based on New Research Evidence. Task No 68, Part 1. London School of Hygiene and Tropical Medicine, Water Engineering and Development Centre (WEDC). UK: Loughborough University.

Bravo-Ureta, B.E. and A.E. Pinheiro. 1997. ‘Technical, Economic and Allocative Effi ciency in Peasant Farming: Evidences from the Dominican Republic’. The Developing Economies, 35(1): 48–67.

Breusch, T.S.A. and A.R. Pagan. 1979. ‘A Simple Test for Heteroskedasticity and Random Coeffi cient Variation’ Econometrica, 47(5): 1287–94.

Ensink, J.H. and van der Hoek, W. 2008. ‘Raw Wastewater Use in Agriculture’: Risk Versus Benefi ts’, in L. Fewtrell and D. Kay (eds), Health Impact Assessment for Sustainable Water Management, London, UK: IWA Publishing.

Ensink, J.H.J., T., Mahmood, W., Van der Hoek, L. Raschid-Sally, and F.P. Amerasinghe. 2004. ‘A Nation-wide Assessment of Wastewater Use in Pakistan: An Obscure Activity or a Vitally Important One?’ Water Policy 6(3): 197–206.

Ensink, J.H.J., W. Van der Hoek, Y. Matsuno, S. Munir, and M.R. Aslam 2002. ‘The Use of Untreated Wastewater in Peri-urban Agriculture in Pakistan: Risks and Opportunities’. IWMI Research Report no. 64, International Water Man-agement Institute., Colombo, Sri Lanka, 22 pp.

Fattal, B., P., Yekutiel, and H.I. Shuval. 1986. ‘Cholera Outbreak in Jerusalem 1970 Revisited: The Case for Transmission by Wastewater Irrigated Vegetables’, in I.R. Goldshmith (ed.), Environmental Epidemiology, pp. 49–59. Boca Raton, Florida: CRC Press .


GoP. 1997. ‘On-farm Water Management Field Management’. Ministry of Food, Agriculture and Livestock, Vol. VI, 345 pp. Federal Water Management Cell, Irrigation Agronomy. Government of Pakistan, Islamabad, Pakistan.

Gordon, D.V. 1989. ‘A Revenue–Function Approach to the Measurement of Output-Substitution Possibilities in Agriculture’, Journal of Business and Economic Statistics, 7(4): 483–87.

Green, W.H. 2003. Econometric Analysis. New Jersey, USA: Prentice Hall Inc. Just, R.E. and R.D. Pope. 1978. ‘Stochastic Specifi cation of Production Functions

and Economics Implications’, Journal of Econometrics, 7(1):67–86.———. 1979. ‘Production Function Estimation and Related Risk Considerations’,

American Journal of Agricultural Economics, 61(2):249–57.Kmenta, J. 1986. Elements of Econometrics. New York: Macmillan Publishing

Company.Kretschmer, N., L. Ribbe, and H. Gaese. 2002. ‘Wastewater Reuse for Agriculture’,

in Technology Resource Management and Development: Special Issue: Water Management, Vol. 2, pp. 35. Köln, Germany.

Nishtar, S. 2007. Corruption in Health Sector in Pakistan. Islamabad: Heart File and Transparency international.

Ramirez, F.E., C.C. Lucho, S.E. Escamilla, and L. Dendooven, 2002. ‘Characteris-tics and Carbon and Nitrogen Dynamics in Soil Irrigated with Wastewater for Different Lengths of Time’. Bioresource Technology, 85(2): 179–87.

Rosegrant, M.W., X. Cai, and S.A. Cline. 2002. World Water and Food to 2025: Dealing with Scarcity, pp. XXIV + 332. Washington, D.C.: International Food Policy Research Institute.

Scott, A.C., J.A. Zarazqa, and G. Levine. 2000. ‘Urban-wastewater reuse for crop production in the watershort Guanajuato river basin, Mexico’. IWMI Research Report 43. Colombo, Sri Lanka: International Water Management Institute.

Scott, C.A., N.I. Faruqui, and L. Raschid-Sally. 2004. ‘Wastewater Use in Irrigated Agriculture: Management Challenges in Developing Countries’, in C.A. Scott, N.I. Faruqui, and Raschid-Sally (eds). Wastewater Use in Irrigated Agriculture: Coordinating the Livelihood and Environmental Realities, Wallingford, U.K.: CAB International.

Shuval, H.I. 1993. ‘Investigation of Typhoid Fever and Cholera Transmission by Raw Wastewater Irrigation in Santiago, Chile’, Water Science and Technology, 27(3–4): 167–74.

Shuval, H.I., A. Adin, B. Fattal, E. Rawitz, and P. Yekutiel. 1986. ‘Wastewater Irrigation in Developing Countries: Health Effects and Technical Solutions’, World Bank Technical Paper No. 51, Washington, D.C.: The World Bank.

Van der Hoek, W., M.U. Hassan, J.H.J. Ensink, S. Feenstra, L. Raschid-Sally, S. Munir, R. Aslam, N. Ali, R. Hussain, and Y. Matsuno. 2002. ‘Urban Waste-water in Pakistan: A Valuable Resource for Agriculture’. Research Report 63, Colombo, Sri Lanka: International Water Msnsgement Institute.


Wadud, M.A. 1999. Ph.D. Thesis. ‘Farm Effi ciency in Bangladesh’. Department of Agricultural Economics and Food Marketing, University of Newcastle upon Tyne, U.K.

Wooldridge, J.M. 2003. Introductory Econometrics: A Modern Approach, 2nd edn. Cincinnati, OH: South-Western College Publishing.

Zaidi, A.S. 2005. Issues in Pakistan’s Economy, 2nd edn, Revised and Expanded. Karachi, Pakistan: Oxford University Press.

Zhang, T. and B. DI Xue. 2005. ‘Environmental Effi ciency Analysis of China’s Vegetable Production’. Biomedical and Environmental Sciences, 18: 21–30.

12

Role of Farmers in Protecting Groundwater in Lower Bhavani River Basin of

Tamil Nadu, India

SACCHIDANANDA MUKHERJEE

INTRODUCTION

CONSUMPTION OF NITRATE-CONTAMINATED water poses several short- and long-term health hazards to various age groups (Fewtrell 2004, WHO 2004). Nitrate (NO3) concentration in water used for drinking should be less than 50 milligram per litre (mg/l) (WHO 2004). According to the 1991 report of the Bureau of Indian Stan-dards (BIS), maximum acceptable limit of NO3 in drinking water is 45 mg/l (which is equivalent to 10 mg/l of nitrate-nitrogen). However, maximum permissible limit for the same is set at 100 mg/l, provided there are no alternative source(s) of drinking water.

Due to the large number of sources and diffused entry points, it is diffi cult to monitor the contribution of individual non-point sources (NPS) to the ambient concentration (groundwater quality). It is also not possible to use regulatory approaches like command and control measures and economic instruments and pollution charges to control NPS pollution. Market-based instruments like nitrogen taxes are not feasible in the Indian context at this time,1 although they have been used in some European countries (Rougoor et al. 2001). As a result, NPS pollution control is mostly neglected in India. Both qualitative and quantitative dimensions of protecting drinking water sources

1 In India, nitrogenous fertilisers have been subsidised to encourage their use by farmers. This has lead to over and unbalanced applications of nitrogenous fertilis-ers and the consequent problem of nitrate pollution of the groundwater (NAAS 2005).

Role of Farmers 259

(groundwater) need to be addressed to meet the needs of the people. Approaches like voluntary cooperation of the stakeholders in the adop-tion of agricultural Best Management Practices (BMPs) may be one of the long-term solutions to control NPS pollution of groundwater within the existing regulatory and institutional framework in India.2 In this chapter, the lower Bhavani River Basin in Tamil Nadu has been taken as a case study of NPS pollution.

NITRATE AND HUMAN HEALTH

It is well established that nitrate represents the most oxidised chemical form of nitrogen found in natural systems. Although it is chemically unreactive, it can be microbially reduced to the reactive nitrite form (Majumdar and Gupta 2000). Nitrate is a potential health threat especially to infants, causing the condition known as methaemoglo-binemia, also called ‘blue baby syndrome’. Methaemoglobin (MetHb) is formed when nitrite, formed from the endogenous bacterial conver-sion of nitrate from , oxidises the ferrous iron in haemoglobin (Hb) to the ferric form (Fan et al. 1987). MetHb cannot bind oxygen and the condition of methaemoglobinemia is characterised by cyanosis, stupor and cerebral anoxia (Fan et al. 1987). Under normal condi-tions less than two per cent of the total Hb circulates as MetHb (Fan et al. 1987).

Infants are more susceptible to nitrate toxicity than older children or adults. Nitrate has been implicated in a number of other health outcomes (Bruning-Fann and Kaneene 1993, Ward et al. 2005). These include effects such as cancer (via the bacterial production of N-nitroso compounds), hypertension, increased infant mortality, cen-tral nervous system related birth defects, diabetes, spontaneous abor-tions, respiratory tract infections and changes in the immune system (Gupta et al. 2000, Hill 1999, Kostraba et al. 1992, Kross et al. 1992, Malberg et al. 1978, MMWR 1996, Super et al. 1981).

2 Voluntary cooperation ‘involves individuals or groups moving in concert in a situation in which no party has the power to command the behaviour of others’ (Wondolleck and Yafee 2000).

260 Sacchidananda Mukherjee

Status of Groundwater Nitrate Pollution in India

Paucity of data is the major challenge to understand the degree and extent at which groundwater is polluted in India. The information available from various government agencies is shown in Table 12.1, which indicates that a large number of habitations are affected by groundwater nitrate pollution in India and the number is growing at an alarming pace.3 The data also shows that semi-arid and arid states like Rajasthan, Gujarat, Tamil Nadu and Karnataka have a large number of habitations affected by groundwater nitrate pollution.

In India, water supply authorities mostly prefer curative measures, for example ex post treatment, at a higher incremental cost of water supply from alternative safe sources as compared to precautionary measures, for example ex ante protection of drinking water sources. This has led to an astronomical demand for investment in infrastruc-ture to supply drinking water to rural populace (Mukherjee 2008). For example, allocation of funds by the Government of India under Accelerated Rural Water Supply Programme (ARWSP) alone has gone up from Rs 12,999 million in 1997–98 to Rs 48,166 million in 2006–07, a 271 per cent increase (GoI 2008). The Indian govern-ment allocated Rs 10,399 million to states during 2006–07 to tackle water quality related problems under ARWSP, which is 21.6 per cent of total allocation of funds to states under ARWSP. According to the estimate released by the Rajiv Gandhi National Drinking Water Mission on 31 March 2004, in India 13,958 habitations are affected by drinking water nitrate pollution. The number of nitrate affected habitations has gone up from 4,003 as on 1 April 1999 to 19,387 as on 1 April 2006 (Table 12.1).

3 A habitation means a place where people have settled permanently. Temporary settlements like those of quarry workers, construction workers, farm workers, nomads, and so on will not be classifi ed as habitation. Main habitation means the habitation which goes by the name of census village. Census village consists of a main habita-tion, sometimes called main village, and a number of other habitations attached to it. There may be cases where the census village may consist of a main habitation only (GoI Undated).

Role of Farmers 261

Tab

le 1

2.1:

G

roun

dwat

er N

itra

te-a

ffec

ted

Hab

itat

ions

acr

oss

Indi

an S

tate

s

Stat

e/UT

As o

n 1

Apri

l 200

6As

on

1. A

pril

2005

As o

n 31

Mar

ch 2

004

As o

n 4

Mar

ch 2

003

ARW

SP:

NH

S 20

03As

on

1 Ap

ril 1

999

(1)

(2)

(3)

(4)

(5)

(6)

(7)

And

hra

Prad

esh

22(0

.3)

A

runa

chal

Pra

desh

1

(0.0

1)

A

ssam

11(0

.15)

B

ihar

2,00

0(1

0.32

)12

(0.1

1)50

(0.3

6)

Del

hi

23(0

.15)

Guj

arat

838

(4.3

2)74

8(6

.95)

1,33

6(9

.57)

603

(3.8

9)39

6(5

.41)

762

(16.

0)H

imac

hal P

rade

sh

1

(0.0

1)

Jhar

khan

d 1

(0.0

1)

1(0

.01)

Ja

mm

u &

Kas

hmir

4,07

7(2

9.21

)

Kar

nata

ka4,

077

(21.

03)

2,48

0(2

3.04

)78

(0.5

6)4,

077

(26.

3)11

7(1

.6)

K

eral

a78

(0.4

)79

(0.7

3)29

6(2

.12)

19

(0.2

6)

Mad

hya

Prad

esh

33(0

.17)

50(0

.46)

9(0

.12)

M

ahar

asht

ra

4,55

2(2

3.48

)52

1(4

.84)

48(0

.66)

(Tab

le 12

.1 co

ntin

ued

)


Stat

e/UT

As o

n 1

Apri

l 200

6As

on

1. A

pril

2005

As o

n 31

Mar

ch 2

004

As o

n 4

Mar

ch 2

003

ARW

SP:

NH

S 20

03As

on

1 Ap

ril 1

999

(1)

(2)

(3)

(4)

(5)

(6)

(7)

Oris

sa

1(0

.01)

10(0

.14)

Pu

duch

erry

3

(0.1

)Pu

njab

11

(0.1

)

1(0

.01)

1(0

.01)

R

ajas

than

7,

693

(39.

68)

6,74

2(6

2.63

)7,

882

(56.

47)

3,86

2(2

4.92

)5,

519

(75.

37)

T

amil

Nad

u10

4(0

.54)

104

(0.9

7)23

7(1

.7)

6,93

3(4

4.73

)1,

128

(15.

4)4,

000

(83.

9)U

ttar

Pra

desh

11

(0.0

6)15

(0.1

4)1

(0.0

1)

29(0

.4)

W

est B

enga

l

13

(0.1

8)

All

Indi

a19

,387

(100

)10

,764

(100

)13

,958

(100

)15

,499

(100

)7,

323

(100

)4,

003

(100

)

Sour

ces:

Col

. 2: 2

006

– Lo

k Sa

bha

Star

red

Que

stio

n N

o. 2

57, d

ated

8 D

ecem

ber 2

006.

C

ol. 3

: 200

5– M

inist

ry o

f Rur

al D

evel

opm

ent,

NIC

–Dep

artm

ent o

f Drin

king

Wat

er S

uppl

y.

Col

. 4: 2

004

– R

ajya

Sab

ha U

nsta

rred

Que

stio

n N

o. 3

88 d

ated

22

Febr

uary

200

6.

Col

. 5: 2

003a

– L

ok S

abha

Uns

tarr

ed Q

uest

ion

No.

196

1, d

ated

4 M

arch

200

3.

C

ol. 6

: 200

3b –

Acc

eler

ated

Rur

al W

ater

Sup

ply

Prog

ram

me

(AR

WSP

), N

atio

nal H

abita

tions

Sur

vey

(NH

S) –

200

3.

Col

. 7: 1

999

– R

ajya

Sab

ha U

nsta

rred

Que

stio

n N

o. 3

146,

dat

ed 1

9 D

ecem

ber 2

001

and

Lok

Sabh

a U

nsta

rred

Que

stio

n N

o. 1

961,

da

ted

4 M

arch

200

3.N

ote:

Fi

gure

in

the

pare

nthe

sis s

how

s th

e pe

rcen

tage

of

tota

l nu

mbe

r of

nitr

ate-

affe

cted

hab

itatio

ns i

n In

dia

for

the

corr

espo

ndin

g pe

riod.

(Tab

le 12

.1 co

ntin

ued

)

Role of Farmers 263

Status of Groundwater Nitrate Pollution in Tamil Nadu

In 2000, the Comptroller and Auditor General of India reported that about 10 per cent of water sources in Tamil Nadu are not potable due to excessive nitrate (CAG 2000: 42). Foster and Garduño (2004) reported an elevated concentration of nitrate in drinking water wells during dry season at numerous locations in Tamil Nadu. The nitrate-affected belt mainly covers the western districts of Tamil Nadu. In Coimbatore and Dharmapuri districts of western zone, more than 20 per cent of drinking water wells had nitrate concentration greater than 50 mg/l and in a large number of wells nitrate concentration exceeded 100 mg/l. Infi ltration or leaching of nitrate from human and animal excreta appeared to be the major cause of groundwater nitrate in those areas.

For the study, district-wise groundwater quality information was collected from the Tamil Nadu Water Supply and Drainage (TWAD) Board to identify nitrate-affected districts for 2004. The analysis showed that 792 habitations in Tamil Nadu, with a population of 390,100 are affected by drinking water nitrate pollution alone, and another 902 habitations with a population of 356,124 are affected by nitrate along with other pollutants. Nitrate affected-habitations mostly fall in the northern and north-western districts of Tamil Nadu. Nitrate-affected population of Coimbatore district is 60,635 and Erode district is 33,947, which is 8.1 per cent and 4.5 per cent of total nitrate-affected population of Tamil Nadu respectively. Large parts of Erode and Coimbatore districts fall within the Bhavani River Basin.

Bhavani River is the second largest perennial river of Tamil Nadu, and one of the most important tributaries of Cauvery River. The Bhavani Sagar reservoir, the Bhavani River and three diversions from the river, namely Arakkankottai, Thadapalli, Kalingarayan (known as old system) and a canal from the reservoir known as the Lower Bhavani Pro-ject (LBP) canal, form the lower Bhavani River Basin (Maps 12.1 and 12.2 ). Due to growing incidence of nitrate concentration in ground-water in the basin, the environmental sustainability of safe drinking water sources is at stake. A similar situation prevails in several other parts of India and various developing countries (Panda and Behera 2003, Agrawal et al. 1999, Duda 1993, Handa 1986). The lower

264 Sacchidananda MukherjeeM

ap 1

2.1:

Lo

cati

on M

ap o

f the

Low

er B

hava

ni R

iver

Bas

in, T

amil

Nad

u

Sour

ce:

GIS

/TW

AD

Boa

rd, C

henn

ai &

Mat

s Lan

ners

tad

(200

6) (P

erso

nal C

omm

unic

atio

n).

Role of Farmers 265M

ap 1

2.2:

St

udy

Vill

ages

in th

e Lo

wer

Bha

vani

Riv

er B

asin

, Tam

il N

adu

Sour

ce:

GIS

/TW

AD

Boa

rd, C

henn

ai &

Mat

s Lan

ners

tad

(200

6) (P

erso

nal C

omm

unic

atio

n).


Bhavani River Basin is an extensively irrigated area, and farmers use nitrogenous fertilisers in excess of the doses recommended by the Tamil Nadu Agricultural University (Shanmugam and Mukherjee 2004). As a result, high concentration of nitrate has been reported in both shallow and deep aquifers. Andamuthu and Subburam (1994) reported that on an average, 36.43 per cent of the groundwater samples in LBP main canal command area had nitrate concentration more than the maximum limit (45 mg/l) fi xed by WHO in 1984. They attributed the usage of commercial fertilisers as the major source of high concentration of nitrate in groundwater samples.

Secondary data on groundwater quality indicates that the level of nitrates in the groundwater is high (>100 mg/l) in many pockets of Coimbatore and Erode districts where the basin is located. In some instances, the public water supply authority has provided drinking water from alternative sources to nitrate-affected rural habitations.4 However, a large section of society is still dependent on decentralised drinking water systems and exposed to high nitrate content drinking water. It is expected that drinking nitrate-contaminated water may have various short- and long-term health impacts. However, due to inadequate secondary health information this cannot be confi rmed.

ECONOMICS OF NON-POINT SOURCE (NPS) POLLUTION CONTROL

Researchers argue that unless farmers foresee any positive, distinctive, private and economic benefi t in the adoption of environmentally benign agricultural practices, they will not adopt any methods to protect groundwater resources that are under open access regime. Unlike other natural resources which fall under local common resource pool such as forestry, fi sheries, grazing land and irrigation water, the private benefi ts of protecting groundwater are not distinct and cannot be parcelled out to individuals involved in conservation. Since in India groundwater falls mostly under free access regime and some

4 This was mostly done from the deep aquifers fi tted with power pumps, and/or bringing water from the Bhavani River either directly or indirectly from infi ltration wells. Dual water supply systems are also in operation in some regions.

Role of Farmers 267

of the services it provides have characteristics of public good, farmers will not incur any private costs to ensure public benefi ts (for example, safe drinking water).

In developed countries, farmers are provided with economic incen-tives such as conservation reserve programme, countryside stewardship programme, and so on to protect groundwater for the comparatively large urban and semi-urban consumers (Brouwer et al. 2003). The difference between polluter and victim (consumer) is distinct in devel-oped countries and consumers’ willingness to pay to avert pollution is often studied to protect groundwater from farming activities. But in India, the difference between the polluter and victim (consumer) is blurred, for polluters (farmers) themselves are sometimes victims (consumers of groundwater). Therefore, we have to treat individual farmers as consumers and study their willingness to pay (incur costs) in terms of adoption of BMPs to protect groundwater.

Why Farmers Are Willing to Protect Groundwater

Bergstrom et al. (2001), Boyle et al. (1994), and Poe and Bishop (2001) argue that in the absence of objective information, people form subjective perceptions about their water quality. Subjective perceptions of water quality are infl uenced by their socioeconomic backgrounds and their access to general and specifi c information on water qual-ity. Bergstrom and Dorfman (1994) studied the potential sensitivity of environmental resource valuation to information concerning the resource. They studied the impact of characteristic and service infor-mation on the economic value of groundwater quality and concluded that changes in the joint levels of information may cause signifi cant changes in groundwater quality valuation behaviour.

In their research, Ready and Henken (1999) demonstrated that a well owner’s optimal self-protection from nitrate contaminated groundwater is subject to his/her subjective probability risk percep-tions that the well is contaminated, which is supported by regular well water test results. They showed that in Kentucky, USA, optimal self-protection could reduce a well owner’s expected damage from nitrate contamination by 38 per cent. Bosch and Pease (2000) have argued that producers’ and consumers’ risk perceptions and preferences can affect perceived costs and benefi ts of adoption of water quality


protection measures. Uncertainty about the level of pollution related damage to water resources is likely to increase the perceived benefi ts of a given quantity of water quality protection practice. Public policies to reduce uncertainty about the costs and benefi ts of water quality protection practices may produce net social benefi ts.

Successful risk assessment and risk communication to the stake-holders is important to induce them to adopt measures to protect groundwater quality. Fessenden-Raden et al. (1987) argue that risk communication is neither a one-way transfer of information nor is it a single or discrete event, but a process involving interactions over time between senders and receivers of information about a risk or vulnerability. Taking account of the socioeconomic characteristics, concerns and priorities of the information recipients is an important aspect towards successful risk communication.

It is worth considering as to how effective the provision of scien-tifi c information related to groundwater quality, such as laboratory water test results, could be to make farmers understand the prevail-ing groundwater quality situation in the sample villages. Testing of individual wells for possible nitrate contamination and intimation of test results during a questionnaire survey may not reveal the actual groundwater quality scenario prevailing in the village as it is a dynamic process which varies over time and space. Therefore, instead of provid-ing sample household specifi c nitrate concentration in drinking water, we provided general information on groundwater nitrate situation prevailing in the basin, along with the sources of groundwater nitrate pollution and possible health hazards of consuming high nitrate-contaminated drinking water through information leafl et.

METHODOLOGY AND DATA SOURCES

The study in this chapter is based on both primary and secondary information collected from various sources. Prior to the main primary survey, a pilot survey was carried out among 15 households from the two selected villages of Kemganaicken Palayam and Madampalayam. The objective of the survey was to test the questionnaire and famil-iarise the fi eld assistants with the same. To understand the factors infl uencing farmers’ subjective risk perceptions about groundwater

Role of Farmers 269

quality, binary choice Probit, homoscedastic and heteroscedastic, models were estimated.5

PRIMARY HOUSEHOLD SURVEY

Characteristics of the Sample Villages

To capture the spatial variations across the basin, we selected six villages based on their sources of irrigation and long-term ground-water nitrate concentration. Out of these, Elathur is at the head reach of the LBP canal and Kalingiam is at the middle reach of the LBP canal. Kondayampalayam depends on Arrakankottai canal and Appakoodal depends on the Bhavani River for irrigation. The last two, Madampalayam and Kemganaicken Palayam, use groundwater (Map 12.2). Apart from surface water sources, groundwater is also used extensively for irrigation in the villages under study.

Apart from the sources of irrigation, the villages differ in their level of urbanisation and socioeconomic status. Appakoodal, Elathur and Kemganaicken Palayam are Town Panchayats (TPs) and Kalingiam, Kondayampalayam and Madampalayam are Village Panchayats (VPs). Out of the six sample villages from three irrigation systems, old, new and rain-fed, one TP and one VP falls under each of the systems (Table 12.2). Appakoodal, Kemganaicken Palayam and Madampalayam are highly polluted with more than 50 per cent of the samples from regularly observed wells taken by TWAD Board during May 1991 to May 2005 having more than 50 mg/l NO3 concentration. Elathur, Kalingiam and Kondayampalayam were moderately affected with less than 50 per cent of the regularly observed wells’ samples having more than 50 mg/l NO3 concentration (Table 12.2).

A pre-structured questionnaire survey was administered to 395 agricultural households spread across the six villages in the basin during June to July 2006. The survey involved collection of both quantitative and qualitative information from the sample households. We adopted random sampling procedure to select the sample households from the nitrate-affected villages, since stratifi cation requires at least one of the

5 Greene (2003) and Long (1997) provide details on binary choice Probit models.


Tab

le 1

2.2:

Gro

undw

ater

Nit

rate

Pol

luti

on in

the

Stud

ied

Vill

ages

Nam

e of t

he S

ampl

e Vill

age

(Vill

age C

ode)

Sour

ce(s)

of I

rrig

atio

n

NO

3 C

once

ntra

tion

(in m

g/l)

% o

f Vill

ages

hav

ing

NO

3 C

once

ntra

tion

Aver

age

Rang

e>5

0 m

g/l

> 10

0 m

g/l

Kem

gana

icke

n Pa

laya

m (T

P) (K

NP)

Smal

l dam

, gro

undw

ater

(ope

n w

ells

and

bore

wel

ls) a

nd ri

ver p

umpi

ng47

.90–

106

50.0

4.5

Mad

ampa

laya

m (V

P) (M

DP)

Mos

tly ra

in-f

ed a

nd p

artly

gro

undw

ater

(o

pen

wel

ls an

d de

ep b

ore

wel

ls)

128.

70–

320

77.3

54.5

Elat

hur (

TP)

(ELA

)LB

P ca

nal a

nd g

roun

dwat

er (o

pen

wel

ls an

d de

ep b

ore

wel

ls)34

.51–

120

23.1

11.5

Kal

ingi

am (V

P) (K

AL)

The

LB

P ca

nal a

nd g

roun

dwat

er (o

pen

wel

ls an

d de

ep b

ore

wel

ls)24

.30–

134

13.0

4.3

Kon

daya

mpa

laya

m (V

P) (K

DP)

The

Ara

kkan

kott

ai c

anal

and

gro

undw

ater

(o

pen

wel

ls an

d de

ep b

ore

wel

ls)49

.72.

7–11

544

.04.

0

App

akoo

dal (

TP)

(APP

)T

he B

hava

ni ri

ver a

nd g

roun

dwat

er

(ope

n w

ells

and

deep

bor

e w

ells)

50.0

10–1

0553

.83.

8

Sour

ces:

TW

AD

Boa

rd, C

henn

ai (P

erso

nal C

omm

unic

atio

n) a

nd P

rimar

y Su

rvey

con

duct

ed b

y th

e au

thor

.

Role of Farmers 271

criteria, background nitrate concentration of drinking water of indi-vidual households, income of the households or land holding size, and so on absent in the household level data from secondary sources.

On an average, 60 agricultural households were randomly selected from each of the six villages on the basis of their owning agricultural land and their interest in the subject of research. Voluntary participa-tion of the households was sought for interviews, based on how much time they could give and their interest on our study. Face-to-face interviews were conducted with the head of the household or with any other person of the family familiar with farming activities. Both the information leafl et and the questionnaire were translated into Tamil, the local language, and a background of the objectives, scope and coverage of the study were given before starting the interviews.

The questionnaire was designed to capture several aspects such as farmers’ perceptions about quality of groundwater and drinking water; factors infl uencing farmers’ willingness to protect groundwater from NPS pollution; willingness to support local government to supply safe drinking water; socioeconomic background; sources of agricul-tural information / consultation / membership in social participatory institutions; willingness to adopt agricultural BMPs; agricultural and farm-management practices; details of crops and chemical use; animal waste management practices and access to sewage and sanitation.

Socio-economic Characteristics of Sample Households

The 395 sample households constituted 3 per cent of the total households (13,278) of the selected villages according to the Census of India (2001). This varied from 2.3 per cent in Appakoodal to 6.2 per cent in Madampalayam. Our sample population constituted 3.4 per cent (2.6 to 6.9) of the total population of the villages which was 48,230, according to Census of India, 2001. Average family size was 4.2, comparatively higher than the national census fi gures.

The sample households together held 695.01 hectare of agricultural land, which is 12.4 per cent of 5,592.3 hectare, the total agricultural land of the villages under study. In Elathur, 8.2 per cent and in Kondayampalayam 25.7 per cent of the agricultural land was owned by sample households. Total cropped area as a percentage of total


geographical area varied from 56 per cent in Appakoodal to 92 per cent in Madampalayam, with an average of 69 per cent. Average land holding was 1.8 hectare which varied from 1.2 hectare for Appakoodal to 2.6 hectare for Kondayampalayam. A list of descriptive statistics is provided in Table 12.3.

BASIC FINDINGS Sources of Drinking Water

In the villages surveyed, 27.95 per cent—11.62 per cent in Kalingiam to 60.29 per cent in Kemganaicken Palayam—of the sample house-holds depended on open wells to meet their drinking water needs. Only 49 per cent of the households received water supply, either through house connection (10.53 per cent) or through stand posts (38.5 per cent). Table 12.4 shows that 50 per cent of our sample households depended on shallow or deep groundwater to meet drinking water needs. More than 82 per cent of the households in Kemganaicken Palayam depended on groundwater for drinking. Town Panchayat cannot provide drinking water due to sparsely settled population and inadequate supply network. Since Appakoodal has its independent water supply scheme, which draws water from the Bhavani river (1.6 million litre per day[mld]), the dependence on groundwater for drinking is comparatively less, 23 per cent. However, almost fi ve per cent of households depended on water tankers provided by the local industry as they were not covered under centralised drinking water network.

Farmers’ Perceptions about Groundwater and Drinking Water Quality

Respondents were asked to rank drinking water quality according to their perceptions. A fi ve-point Likert-type scale was constructed on the basis of fi ve categories of perceptions. The average drinking water quality scores with respect to the farmers’ perceptions (Table 12.5) were divided into three categories, namely drinking water quality of supplied water, where both house connection and sand post were taken into consideration; drinking water independently sourced,

Role of Farmers 273

Tab

le 1

2.3:

Sa

mpl

e V

illag

es a

nd B

asic

Sam

ple

Cha

ract

eris

tics

Nam

e of t

he V

illag

e AP

PEL

AK

ALK

NP

KD

PM

DP

ALL

Num

ber o

f obs

erva

tions

6572

6668

6460

395

Des

crip

tion

Mea

n ±

Stde

v M

ean

± St

dev

Mea

n ±

Stde

vM

ean

± St

dev

Mea

n ±

Stde

vM

ean

± St

dev

Mea

n ±

Stde

vA

ge (i

n co

mpl

eted

yea

rs)

44 ±

13

50 ±

12

42 ±

13

44 ±

12

47 ±

13

51 ±

12

46 ±

13

(23–

66)

(25–

80)

(21–

71)

(20–

82)

(22–

76)

(28–

80)

(20–

82)

Educ

atio

n (in

yea

rs)

7.5

± 5.

66.

9 ±

5.1

6.7

± 4.

98.

5 ±

3.4

7.6

± 5

5.1

± 4.

77.

1 ±

4.9

(0–1

8)(0

–18)

(0–1

7)(0

–15)

(0–1

6)(0

–15)

(0–1

8)Ec

onom

ical

ly a

ctiv

e pe

rson

in

a fa

mily

1.

9 ±

1.3

1.9

± 1.

11.

9 ±

1.1

1.6

± 0.

71.

9 ±

11.

5 ±

0.7

1.8

± 1

(1–9

)(1

–5)

(1–7

)(1

–3)

(1–4

)(1

–4)

(1–9

)Pe

r cap

ita la

nd h

oldi

ng

(in h

ecta

re)

0.34

± 0

.27

0.42

± 0

.31

0.4

± 0.

320.

49 ±

0.4

20.

63 ±

0.5

30.

33 ±

0.2

50.

44 ±

0.3

8(0

.03–

1.82

)(0

.05–

2.02

)(0

.08–

1.35

)(0

.13.

04)

(0.1

–3.0

4)(0

.04–

1.42

)(0

.03–

3.04

)Pe

r cap

ita in

com

e (in

Rs./

Year

) 7,

613

± 5,

764

8,68

8 ±

11,5

0510

,699

± 8

,865

9,23

9 ±

9,51

211

,706

± 1

0,12

48,

235

± 9,

123

9,36

2 ±

9,40

3(1

,000

–33,

333)

(1,0

00–6

6,66

7)(2

50–4

1,14

9)(1

,250

–60,

400)

(1,6

67–5

8,79

6)(3

75–4

0,00

0)(2

50–6

6,66

7)R

esid

ing

in th

e vi

llage

(in

year

s)

83 ±

32

80 ±

29

81 ±

33

57 ±

42

68 ±

41

89 ±

24

76 ±

36

(1–1

00)

(1–1

00)

(4–1

00)

(10–

200)

(1–1

00)

(5–1

00)

(1–2

00)

Num

ber o

f chi

ldre

n (b

elow

5

year

s of a

ge) i

n th

e fa

mily

0.06

± 0

.30

0.21

± 0

.53

0.20

± 0

.59

0.50

± 0

.97

0.13

± 0

.38

0.22

± 0

.61

0.22

± 0

.62

(0–2

)(0

–2)

(0–3

)(0

–4)

(0–2

)(0

–3)

(0–4

)

Sour

ce:

Prim

ary

surv

ey c

ondu

cted

by

the

auth

or.

Not

e: Fi

gure

s in

pare

nthe

sis sh

ow th

e ra

nge

for t

he c

orre

spon

ding

ave

rage

val

ue.


Tab

le 1

2.4:

So

urce

s of

Dri

nkin

g W

ater

(in

Per

cent

age

of S

ampl

e H

ouse

hold

s)

Nam

e of V

illag

e O

wn

Han

d Pu

mp

Ow

n Po

wer

pum

p O

wn

open

W

ell

Supp

ly

Wat

er—

hous

e C

onne

ctio

n

Supp

ly W

ater

–

Sand

Pos

t

Publ

ic

Han

d Pu

mp

Com

mun

ity

Well

W

ater

T

anke

r N

umbe

r of

Resp

onde

nts

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

App

akoo

dal

0.00

3.59

19.7

40.

7771

.28

0.00

0.00

4.62

65El

athu

r 2.

4316

.20

23.2

614

.93

36.6

92.

084.

400.

0072

Kal

ingi

am

31.0

61.

5211

.62

36.3

60.

0014

.14

2.78

2.53

66K

emga

naic

ken

Pala

yam

2.

2118

.38

60.2

90.

0017

.65

0.00

1.47

0.00

68K

onda

yam

pala

yam

1.30

11.7

232

.03

9.11

42.7

12.

081.

040.

0064

Mad

ampa

laya

m

3.89

8.89

19.4

40.

8366

.39

0.56

0.00

0.00

60A

ll V

illag

es

6.81

10.2

127

.95

10.5

338

.46

3.16

1.69

1.18

395

Sour

ce:

Prim

ary

surv

ey c

ondu

cted

by

the

auth

or.

Role of Farmers 275

Tab

le 1

2.5:

Fa

rmer

s’ P

erce

ptio

ns a

bout

Dri

nkin

g W

ater

Qua

lity

Nam

e of V

illag

eQ

ualit

y of

Su

pplie

d W

ater

∗

Qua

lity

of o

wn

Wat

er S

ourc

e∗

Qua

lity

of w

ater

fr

om P

ublic

Han

d Pu

mp

and

Publ

ic

Well

s∗

Perc

enta

ge o

f Re

spon

dent

s Who

C

ollec

t Wat

er a

s th

eir O

wn

Sour

ce(s)

of

Dri

nkin

g W

ater

is

Pollu

ted

Perc

enta

ge o

f Re

spon

dent

s Sa

tisfi e

d w

ith

thei

r Dri

nkin

g W

ater

Qua

lity

Perc

enta

ge o

f Re

spon

dent

s W

ho T

hink

thei

r G

roun

dwat

er is

Po

llute

d(1

)(2

)(3

)(4

)(5

)(6

)(7

)

App

akoo

dal

3.9

(2–4

)2.

9 (2

–4)

–42

8543

Elat

hur

3.8

(3–5

)3.

2 (2

–4)

2.5

(2–4

)54

8125

Kal

ingi

am3.

9 (2

–4)

3.9

(2–5

)3.

8 (3

–4)

2110

08

Kem

gana

icke

n Pa

laya

m3.

6 (2

–5)

3.4

(1–5

)3.

5 (2

–5)

6660

44K

onda

yam

pala

yam

4.0

(3–5

)3.

8 (2

–4)

5.0

(5–5

)30

9211

Mad

ampa

laya

m3.

9 (2

–4)

3.0

(2–4

)–

4684

28A

ll V

illag

es

3.9

(2–5

)3.

4 (1

–5)

3.3

(2–5

)46

8428

Sour

ce:

Prim

ary

surv

ey c

ondu

cted

by

the

auth

or.

Not

e: ∗ i

mpl

ies r

espo

nden

ts w

ere

aske

d to

rank

thei

r drin

king

wat

er q

ualit

y ac

cord

ing

to th

eir p

erce

ptio

ns in

to a

fi ve

Lik

ert-

type

scal

e, th

at

is ve

ry g

ood

(5),

good

(4)

, fai

r (3

), ba

d (2

) an

d ve

ry b

ad (

1). F

igur

es in

par

enth

esis

show

the

rang

e fo

r th

e co

rres

pond

ing

aver

age

valu

e.


which covers personal hand pumps, power pumps, open wells and drinking water quality of public hand pumps. The average score of supplied water quality is 3.9 (3.6–4.0), which implies that supplied water quality lies in between fair (3) to good quality (4). However, in four out of six villages, some farmers reported that supplied water quality is poor (2). For example in Appakoodal, 72 per cent and in Madampalayam 67 per cent of the respondents, though dependent on supplied water, were not satisfi ed with the water quality. The average score of independent source of drinking water quality varied from 2.9 to 3.9, implying that it lay between poor (2) and good quality (4), depending on the place of residence. For example, in Kemganaicken Palayam, 66 per cent of the respondents collected water from alterna-tive sources as their own sources of drinking water is polluted. On an average, 46 per cent of the respondents collected water as their own water sources did not offer quality potable water.

By asking four different questions, the survey attempted to capture individual farmer’s perceptions (subjective) about groundwater and drinking water quality. On an average, 84 per cent of the sample households were satisfi ed with their drinking water quality and only 28 per cent of the sample households thought that their ground-water was polluted. However, in case of Appakoodal, Kemganaicken Palayam and Madampalayam, more than 40 per cent of the sample households reported groundwater pollution. On an average, 45 per cent of the households collected water from other source as their own sources were polluted. In case of Elathur, though moderately polluted, 54 per cent of the sample households collected water from outside due to water quality problem. In Kemganaicken Palayam and Madampalayam, more than 60 per cent of the households collected water from outside sources. In Appakoodal, 43 per cent of the sample households collected water from outside sources, which goes against the actual groundwater quality perception. Respondents were sceptical to reveal the actual groundwater quality situation to the researchers for they feared intimidation from the local industry. Thus farmers’ perceptions varied signifi cantly across the study villages.

On an average, 24 per cent of the sample households purifi ed the collected water for drinking and cooking purposes. In Kalingiam 8 per cent and in Kemganaicken Palayam 34 per cent of the

Role of Farmers 277

households purifi ed their water before use. But boiling further increases the concentration of nitrate. , Therefore boiling is not recommended if there is presence of nitrate in the water. Nitrate cannot be removed by using plain cloth or candle type fi lter. Thus the purifi cation methods adopted by the sample households would not reduce the high presence of nitrate in water (Table 12.6).

Testing of soil and application of fertilisers on the basis of soil test results is considered as one of the most important agricultural BMPs, which could help farmers to improve fertiliser-use effi ciency. The survey results showed that on an average 42 per cent of farmers tested their soil, which varied from 26 per cent in Kemganaicken Palayam to 61 per cent in Kondayampalayam. Though testing of soil samples once in a year is suggested, farmers in the sample villages tested their samples only after a gap of fi ve years.

The soil testing services provided by the government is not adequate to serve all the farmers and the transaction costs associated with test-ing samples at agricultural university or private laboratories is high. However, on an average, only 36 per cent of farmers were willing to use fertilisers according to the recommendation made after soil tests. Around 35 per cent of the sample households were using bio-fertilisers, such as Rhizobium, Azotobacter/Azospirillum, Acetobacter, blue–green algae and Azolla, Phosphatika, Phosphobacterial, and so on for their crops, which varied signifi cantly across the villages, from 8 per cent in Madampalayam to 55 per cent in Kondayampalayam. On an average, 17 per cent of the sample households were practis-ing organic farming which signifi cantly varied across villages, from minimum two per cent in Madampalayam to maximum 34 per cent in Kondayampalayam. On an average 13 per cent of the sample households had biogas plants and approximately 38 per cent of daily animal waste went to the biogas plant, with a minimum of 10 per cent and a maximum of 90 per cent). In Elathur, only 3 per cent of the sample households had biogas plants, whereas in Kemganaicken Palayam, 49 per cent of the sample households were using biogas. Only 32 per cent of the sample households had toilets within their premises, which they were using, which again varied signifi cantly across villages, with minimum nine per cent in Kalingiam to maximum 56 per cent in Kemganaicken Palayam.


Tab

le 1

2.6:

Far

mer

s’ W

ater

Pur

ifi ca

tion

Pra

ctic

es (

in P

erce

ntag

e of

Tot

al N

umbe

r of

Sam

ple

Hou

seho

lds)

Met

hods

of W

wat

er P

urifi

catio

nAp

pako

odal

Elat

hur

Kal

ingi

amK

emga

naic

ken

Pala

yam

Kon

daya

mpa

laya

mM

adam

pala

yam

Aver

age

Filte

ring

usin

g-pl

ain

clot

h 5

122

110

76

Boi

ling

1014

421

2511

14W

ater

fi lte

r––c

andl

e ty

pe3

02

12

113

Wat

er fi

lter—

Oth

ers

00

01

00

0C

hem

ical

trea

tmen

t (C

hlor

inat

ion,

us

ing

Cam

phor

, Alu

m, L

ime,

and

so

on

) 0

00

00

00

No

purifi

cat

ion

(in %

)82

7492

6673

7177

Sour

ce:

Prim

ary

surv

ey c

ondu

cted

by

the

auth

or.

Role of Farmers 279

RESULTS

Factors Infl uencing Farmers’ Perceptions about Groundwater Quality

To understand the farmers’ perceptions about groundwater quality in their areas, respondents were asked if they thought their groundwater was polluted. On an average, only 28 per cent of the sample households thought that their groundwater was polluted, which varied signifi -cantly across the villages from minimum 8 per cent in Kalingiam to maximum 44 per cent in Kondayampalayam. In case of Appakoodal, Kemganaicken Palayam and Madampalayam more than 40 per cent of the sample households responded affi rmatively to groundwater pollution. Among the six villages selected for our primary question-naire survey, three villages, namely Appakoodal, Kemganaicken Palayam and Madampalayam, had comparatively higher groundwater nitrate concentration which also refl ected in the perception survey. Farmers from the three villages thought that their groundwater was polluted, whereas the farmers from other three villages responded negatively.

The results showed that apart from various socioeconomic char-acteristics of a respondent, the characteristics of groundwater, captured through various dummy variables, such as sources of drinking water, drinking water quality and village dummy, signifi cantly infl uenced the perceptions. Households with larger per capita landholding are more likely to perceive that their groundwater is polluted. Per capita land holding is a measure of a household’s income, which shows that higher-income households perceive greater risk of groundwater pol-lution. Farmers who had knowledge about the impact of agricultural practices on groundwater quality were more likely to perceive that their groundwater is polluted. Farmers’ knowledge about agricultural and environmental BMPs positively infl uence their perceptions. How-ever, farmers who had in-house toilets, used bio-fertilisers, practised organic farming and had a biogas plant, defi ned as pro-environment farmers, were less likely to accept that their groundwater was polluted. Irrespective of the sources of drinking water, farmers perceived that their groundwater was polluted.


Farmers who had access to better quality drinking water from their own sources, that is private open well, own hand pump and power pump, or through other sources such as house connection and stand posts, were less likely to perceive that their groundwater is polluted. Households with higher number of children less than fi ve years of age were less likely to accept that their groundwater was polluted. Sample households from comparatively higher nitrate-concentrated villages, namely Appakoodal, Kemganaicken Palayam and Madampalayam, were more likely to accept that their groundwater was polluted, while the opposite is true for other villages, namely Kalingiam, Kondayampalayam and Elathur. The results showed that farmers’ subjective perceptions about groundwater quality mimicked the actual groundwater nitrate situation of the villages.

Factors Infl uencing Farmers’ Willingness to Protect Groundwater Quality

We asked farmers to reveal their willingness, or reluctance, to protect groundwater from NPS pollution. On an average, 56 per cent of the respondents revealed that they were willing to protect groundwater quality as a source of drinking water. The willingness to protect varied signifi cantly across the sample villages, with minimum 38 per cent in Kalingiam and Kondayampalayam and maximum 78 per cent in Kemganaicken Palayam.

The results reveal that farmers, with better knowledge about the impact of agricultural practices on groundwater quality, were willing to protect groundwater from NPSs. They have been staying for a long time in the sample villages, having larger per capita land holding, were reluctant to protect groundwater quality. Farmers’ membership in participatory social institutions such as Cooperative Milk Producers’ Association, Farmers’ Association, and so on positively infl uenced their willingness, whereas sources of agricultural information nega-tively infl uenced willingness across all the villages. However, when the model is corrected for the presence of heteroskedasticity, sources of agricultural information showed positive relationship with willingness for moderate nitrate affected villages.

In all high-nitrate-affected villages—Appakoodal, Kemganaicken Palayam and Madampalayam—farmers were willing to protect

Role of Farmers 281

groundwater quality, whereas in other villages such as Kalingiam, Kondayampalayam and Elathur, farmers appeared reluctant. Farmers having knowledge about agricultural BMPs and their envi-ronmental benefi ts were more likely to protect groundwater quality. In all high nitrate affected villages such as Appakoodal, Kemganaicken Palayam and Madampalayam, farmers were willing to protect ground-water quality, whereas in other villages farmers appeared reluctant to follow suit.

Factors Infl uencing Farmers’ Willingness to Support Local Government to Supply Safe Drinking Water

Since some farmers collect drinking water as the quality of their own sources is problematic. We asked them to reveal their willingness, or reluctance, to support the local government in supplying water from alternative safe sources or to set up state-of-the-art water treatment plant, by contributing, supporting and taking initiative. The results showed that on an average 38 per cent (a minimum of 20 per cent in Kalingiam to a maximum of 58 per cent in Madampalayam) of the sample farmers were willing to support the local government, which varied signifi cantly across the sample villages.

The results show that irrespective of sources of drinking water, farmers were willing to support the local government in terms of ini-tiatives and contribution to supply safe drinking water. Farmers with access to relatively good quality drinking water were reluctant to sup-port the local government. Farmers’ perceptions about groundwater quality infl uenced their willingness, and the households who purifi ed water were also supportive. Households from Appakoodal, Kalingiam and Kondayampalayam were less likely to support the government as their own sources of groundwater were comparatively less pol-luted (Kalingiam and Kondayampalayam) or they already have good access to supplied water (Appakoodal). Households from Elathur, Kemganaicken Palayam and Madampalayam were willing to support government, as their own sources of drinking water were comparatively more polluted (Kemganaicken Palayam and Madampalayam), and they want to improve the access to supplied water (Elathur).


CONCLUSION

In the lower Bhavani River Basin in Tamil Nadu, incidence of growing concentration of nitrate in the groundwater shows that environmental sustainability of safe drinking water sources is at stake. Similar situa-tions also prevail in several other parts of India and other developing countries. This study attempts to understand the farmers’ perceptions about groundwater and their willingness to protect it from NPS pol-lution either individually or collectively. The results show that:

z Farmers from villages with comparatively high groundwater nitrate contamination correctly perceived (subjective) the groundwater quality and were more willing to protect it than farmers from less affected villages. It shows that any groundwater quality protection programme from NPS pollution should take into consideration the site characteristics and socioeconomic characteristics of the stakeholders.

z Farmers’ groundwater quality perceptions (subjective) varied across the and mimicked the actual groundwater nitrate situa-tion. Households, depending on their socioeconomic character-istics, social and information network and the characteristics of the resource (alternative sources and quality of drinking water) derive a subjective risk assessment about the groundwater qual-ity. Regular monitoring of groundwater quality, assessment (objective) of risks of consuming contaminated groundwater and communication of risks to the stakeholders could help the farmers to take measures and initiatives either individually or collectively to protect groundwater from NPS pollution.

z Demand for safe drinking water varied across the villages, based on the variations of socioeconomic characteristics of the sample households and groundwater quality. Farmers’ willingness to protect groundwater quality and their willingness to support local government also varied. The farmers in Appakoodal with higher concentration of groundwater nitrate were willing to protect groundwater quality but reluctant to support local gov-ernment. Adoption of demand-driven approach for the provision of drinking water may not be suitable, especially when the risk

Role of Farmers 283

of drinking contaminated water is not commonly perceived as unhealthy by the consumers.

z Farmers’ knowledge about the impact of agricultural practices on the quality of groundwater signifi cantly infl uences their perceptions about it and willingness to protect it. Therefore, provision of agricultural information and education along with basic agricultural extension services could induce farmers to protect groundwater from NPS pollution.

z Socioeconomic characteristics of the households and the charac-teristics of groundwater or drinking water signifi cantly infl uence the farmers’ perceptions. Knowledge of agricultural BMPs and their impacts on environment positively infl uences farmers’ perceptions and willingness.

The study demonstrates the impact of NPS water pollution on the long term sustainability of safe drinking water. The study builds an argument in favour of voluntary adoption of BMPs as an alternative policy instrument or method to control NPS groundwater pollution. Farmers’ perceptions about agricultural application of chemicals and groundwater quality and their preferences to protect groundwater quality from NPS pollution will help to design appropriate policy instruments at the local, regional and national levels of government. Compared to direct regulation or fi nancial incentives, raising farmers’ information and awareness levels may be a more cost-effective method of increasing adoption of BMPs. Ensuring institutional reforms in delivering basic agricultural extension services such as soil testing services, could be benefi cial for the large scale adoption of BMPs.

Importance of the participatory approach for sustainability of safe sources of drinking water has been acknowledged by the government. In February 2006, Government of India started the National Rural Drinking Water Quality Monitoring and Surveillance Programme and focused on community-based approach for monitoring and surveillance of drinking water quality for rural water supply. Collec-tive action in terms of adoption of measures to protect groundwater from NPS pollution is required for sustainability of safe sources of drinking water.


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13

Industrial Water Pollution and Health Implications

Emerging Issues from Tiruppur, Textile Town of South India

PRAKASH NELLIYAT

INTRODUCTION

WATER IS AN important and unavoidable constituent of life support system. According to the World Health Organisation, ‘the state of human health is inextricably linked to a range of water-related conditions—safe drinking water, adequate sanitation, minimised burden of water-related diseases and healthy freshwater ecosystems’ (WHO 2003). Ill-health is likely to impact the economic status and livelihood of a household.

During the globalisation era, starting from the 1980s, most of the water sources in developing countries have been polluted due to rapid and unscientifi c industrialisation, urbanisation and other anthropogenic reasons. The primary sources of water pollution are: (a) sewage and solid wastes from domestic sector, (b) effl uents, sludge and other solid wastes from industrial sectors (most of it, highly toxic) and (c) residual chemical fertilisers and pesticides discharged by the agriculture sector. In most of the developing countries, proper waste management strategies do not exist. Moreover, the public is not aware about various impacts associated with pollution.

In Asian countries, post-globalisation, the contribution of industries in Gross Domestic Product (GDP) has increased signifi cantly. Most of the polluting industries—tanneries, textiles, paper and pulp, and so on—moved from the developed nations to the developing coun-tries during the post-globalisation era (Dicken 1998, Nelliyat 2005).

288 Prakash Nelliyat

In the developing countries, the ratio of water withdrawn for industrial purpose is higher than the global average and generally most of the water withdrawn by the industries is discharged as effl uents. Hence the environment in general, and water resources in particular, get highly polluted leading to various social and health problems.

In India, the industrial sector discharged 30,729.20 million cubic metre effl uents during 2007 without proper treatment into water bodies. In the small-scale industrial sector, under government initi-atives, 88 Common Effl uent Treatment Plants (CETPs) were con-structed with a total capacity of 560 mld. These plants would cover more than 10,000 small-scale polluting industries in the country (CPCB 2006, Khurana and Romit 2008). But the study done by the Central Pollution Control Board (CPCB 2006) revealed that the CETPs do not perform satisfactorily, largely due to improper opera-tion and maintenance.

Unfortunately, in most of the pollution affected areas, the health impacts are not scientifi cally studied due to the complexity in meth-odology and lack of data. This chapter is an attempt to examine the industrial water pollution problem and possible health risks in the major South Indian textile cluster of Tiruppur. The basic structure of this chapter involves (a) documenting growth of water intensive industries in developing countries and its health implications dur-ing globalisation, (b) diversifi cation of global textile industry and its implications for India, (c) growth of textile industry in Tiruppur with economic and environmental issues such as water pollution, (d ) failure of effl uent treatment plants as a pollution management option, (e) pos-sible health impacts of textile processing and need for epidemiological study and health risk assessment, (g) the continuance of pollution and health risks in Tiruppur as well as political economy and governance issues and (h) conclusion and policy recommendations.

GLOBALISATION, GROWTH OF WATER-INTENSIVE INDUSTRIES AND THEIR HEALTH IMPLICATIONS

From the 1990s, the world has witnessed the emergence and consolida-tion of an economic paradigm which emphasise domestic deregulation

Industrial Water Pollution and Health Implications 289

and removal of barriers to international trade and fi nance. These glo-balisation processes affect the institutional, economic, socio-cultural and ecological determinants of population health.

Due to the establishment of global markets and a global trading system, there has been a continuing increase in manufacture of dif-ferent consumer goods and enhancement of world trade. During globalisation, many developing countries started manufacturing products based on their comparative advantage in production. The massive increase in production, primarily targeted towards the global markets, without providing adequate safeguards for environ-mental management, led to serious environmental damage in the region. Environmental changes can have profound effects on the provision of ‘ecosystem goods and services’ to humankind. The recent industrial development in developing countries poses a severe chal-lenge to the environment and health security.

In poor countries with heavy debts, the proportion of GDP pro-vided by industry grew from 22 to 26 per cent between 1998 and 2002. In contrast, the contribution of industrial production to the GDP of rich countries declined 29 per cent and services making up the bulk of the economy. Overall, however, industrial production continues to grow worldwide, as economies grow (World Bank 2003).

Shiklomanor (2000) estimated the global trends in industrial water use from 1950 to 2000. In 1950, the total world industrial water withdrawal was only about 150 km3, which increased to about 950 km3 in 2000. The estimated actual consumption in 2000 was around 150 km3, which indicates that around 800 km3 water is dis-charged as effl uents. Region-wise analysis reveals that industrial water withdrawal has not increased in the developed region since 1980, instead it has slightly reduced. The industrial water withdrawal in North America reduced from 320 km3 in 1980 to 300 km3 in 2000. In Europe also it reduced from 220 km3 in 1980 to 200 km3 in 2000. But in Asia, a signifi cant increase was recorded throughout the period from 30 km3 in 1950 to 160 km3 in 1980 to 235 km3 in 2000.

Since industries generate considerable amount of wastewater, its safe disposal is a challenge. In developing countries, industries directly discharge their untreated or partially treated effl uents to water bodies. If the water is contaminated with heavy metals, chemicals or


particulates, or loaded with organic matters, this obviously affects the quality of the receiving water body or aquifer. According to the United Nations Industrial Development Organization (UNIDO), human health will be directly affected if the industrial discharge is located upstream of (i) a recreation bathing and swimming area or commercial, recreational or subsistence fi shing grounds, (ii) a point where farmers withdraw water in order to irrigate their crops (iii) a point where a municipality withdraws water for domestic use, or (iv) a point where people without a formal water supply withdraw water for drinking. Water sources get polluted by industries either through direct discharge of effl uents into those or through indi-rect ways like leachate from industrial dumpsites and acid rain (UNIDO 2003).

DIVERSIFICATION OF THE GLOBAL TEXTILE INDUSTRY AND ITS IMPLICATIONS IN INDIA

Textile industry is one of the major water-intensive industries, withdrawing huge quantities of water and discharging effl uents. During 1980s and 1990s, substantial global shifts have occurred in textile production and export. Before 1980, countries like Germany, Italy, France, UK, The Netherlands and USA played a vital role in world textile exports. But by 1995, the dominance of these countries substantially reduced and the share of developing nations, especially Asian countries like China, Korea, Taiwan, India, Pakistan and Thailand, increased (Dicken 1998). The main factor attributed to this shift is the cheap labour in developing nations compared to western countries. Apparently the environmental policies, which are relatively less stringent in developing nations, may have contributed to the shift.

During the globalisation wave, cotton textile and garment industries grew rapidly in India. The country has more than 9 million hectares of area under cotton cultivation with annual production of around 3 million tonnes of cotton. These industries generate substantial employment, income and foreign exchange. The percentage of textiles in the total exports from India doubled from 17 per cent in 1981–82


to 31.6 per cent in 1998–99). Currently the textile industry accounts for about 14 per cent of the national industrial production and about 4 per cent of the GDP. It provides employment opportunities to 35 million people, particularly in the rural and remote areas of the country. Around 10 per cent of excise revenue is obtained from the textile sector (GoI 1999a, 1999b).

The Indian textile sector has been experiencing structural transfor-mation through reduction in the role of the organised mill sector and an increase of the small-scale and cottage sectors such as handlooms, power looms, knitwear and garment making units. These sectors are developing as clusters in a highly decentralised and fl exible industrial networking manner. Tiruppur knitwear cluster is a classic example. To some extent, the industrial policy adopted by the Government of India, which emphasised the growth of small-scale industries, (SSIs) has also favoured the growth of textile industries as clusters. Institutions like the South India Textile Research Association (SITRA), Apparel Export Promotion Council (AEPC) and Textile Committee (TC) have promoted the growth and development of textile industry.

The wet processing segment of textile industry has caused severe pollution. The processing units use huge quantities of water and different chemicals. The effl uents discharged are generally hot, alkaline, strong-smelling, coloured and even containing toxic chemi-cals. Unfortunately, the majority of the textile units, especially the smaller ones, do not treat their effl uents properly and the untreated or partially treated effl uents are discharged into water bodies or on land, or sometimes used for irrigation. The technological development in the wet processing segment is unsatisfactory with most of the small units using traditional processing technology that is not eco-friendly.

Textile consumers in Europe and USA have become more con-cerned about environmentally sound products with eco-labels. Generally, the eco-mark schemes specify that the products should be manufactured in an environmentally-friendly way. This implies that the product or its manufacturing activities should not create any environmental and health consequences for both the consumers of the product as well as the public, through waste disposal. Unfortunately, in the Indian textile industry, eco-labelling criteria is applicable only to product quality and not to the manufacturing process.


ECONOMIC AND ENVIRONMENTAL ISSUES IN TIRUPPUR

Tiruppur is a major knitwear cluster in India with more than 9,000 small-scale units (Figure 13.1). Tiruppur is located at the bank of Noyyal River, a tributary of Cauvery, a major South Indian river, in Coimbatore District of Tamil Nadu. The city contributes 56 per cent of the total cotton knitwear export from India. Industrial growth started in Tiruppur in 1930, and was moderate till 1980. Hence pollu-tion problems did not emerge. But since 1980, the clusters have been manufacturing huge quantities of garments for the export market.

The socioeconomic contribution of the textile industry is substan-tial. Different varieties of knitwear products, which have good domes-tic and international markets, are manufactured in Tiruppur. The knitwear industries in Tiruppur entered into the export market during the early 1980s and have achieved steady growth ever since (Figure 2). The export earnings from Tiruppur during the year 2007 were about Rs 110,000 million (based on current price). This industry provides employment for more than 300,000 people (Nelliyat 2005).

Yarn making and weaving and knitting, or cloth making are the major activities at the fi rst stage in the knitwear industry. In the second stage, textile processing is done that involves bleaching, dyeing and printing of grey cloth. In this stage industries use huge quanti-ties of water and different chemicals and discharge the effl uents into the environment. Besides, a number of other ancillary activities like calendering, rinsing, and so on are also undertaken on a need basis. The third stage involves garment manufacturing which involves activ-ities of cutting, stitching, embroidery, buttoning, labelling, packing and dispatching or exporting (Fig. 13.3). Generally in Tiruppur the activities mentioned in Figure 13.3 are independently undertaken by units as job work. A few entrepreneurs even conduct all the activities in their own factory premises.

The textile industry in Tiruppur, however, is also a large water-user and effl uent discharger. After the exports started the number of processing units as well as their water requirements rapidly increased. In 1980, there were only 26 processing units in Tiruppur. But the number increased over a period and currently more than 700 textile

Industrial Water Pollution and Health Implications 293Fi

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Figure 13.2: Knitwear Garment Export Value from Tiruppur (In Rs crore [1 crore = 10 million]; Base year: 1993–94)

Source: Nelliyat 2005.

processing units are functioning. The size composition analysis of 702 processing units based on their Gross Fixed Assets (GFA) revealed that 28 per cent (197 units) have GFA less than Rs 0.5 million, 57 per cent (400 units), between Rs 0.5 to 2 million and 15 per cent (105 units), more than Rs 2 million (Nelliyat 2005).

At the time of processing, a variety of chemicals and acids are used. Consumption rate of these increases over a period of time in propor-tion to the quantum of cloth processed. The annual consumption of chemicals by the processing units includes 40,000 million tonnes (mt) of soda ash, 3,000 mt of dyes, 6,000 mt of acid, 1,500 mt of wetting agents, 3,000 mt of hypochlorite, 6,000 mt of hydrogen peroxide, 1,000 mt of hydrogen peroxide killer, 120,000 mt of salt, 7,500 mt of caustic soda, 3,000 mt of detergents, 3,000 mt of fi xing agents and 3,000 mt of softening agents (Nelliyat 2005). It is very clear that much of the chemicals and acids used for processing are not retained in the cloth but are discharged as waste material which ultimately leads to high pollution load in the effl uents. The volume of wastewater discharged increased from 4.1 mld in 1980 to 83.41 mld in 2000 (Nelliyat 2005).

The industries discharge their effl uents on land and into Noyyal River. The river carries the effl uents downstream, especially to the system tanks and the Orathapalayam reservoir. Hence the pollution is widespread even in surrounding villages and distant areas and the


Figure 13.3: Major Activities in Tiruppur Knitwear Industry

Source: Nelliyat (2005). * Polluting segments


possibility for contaminating the groundwater, the major source of drinking and irrigation, in residential and agricultural areas is very high. Besides, pollution severely affects the biodiversity and fi sheries’ potential of all surface water sources (MSE 2002, Nelliyat 2005).

Along with the direct discharge of effl uents, the solid wastes (sludge) from the treatment plants are also a threat to the environment. Since all the treatment plants use huge quantities of chemicals like hydrated lime, ferrous sulphate, and so on enormous amount of chemical sludge (33,740 mt/year) is generated (Azeez 2008). The sludge from textile processing units is generally classifi ed as ‘hazardous waste’ as per the Hazardous Waste (Management and Handling) Rules of Gov-ernment of India. Since no proper sludge disposal facilities exist in Tiruppur, all treatment plants store the sludge inside their premises without proper safety measures. This results in leachates contaminat-ing surface and groundwater.

The existing water quality studies clearly show the accumulation effect of pollution in Tiruppur area and downstream of the Noyyal River basin. The groundwater studies indicate that open wells and bore wells in and around Tiruppur and the downstream stretch of Noyyal exhibit high levels of TDS (Total Dissolved Solids) (most areas > 3000 mg/l and some places even up to 11,000 mg/l) and chloride (generally > 2000 mg/l and certain areas up to 5000 mg/l) due to industrial pollution. These values are very much higher than the background levels for this region and groundwater is not suitable for domestic or irrigation use. The surface water studies indicate that the Noyyal River, downstream reservoir (Orathapalayam) and tanks have been affected badly by industrial pollution and the water is unfi t for domestic use, irrigation or fi sheries (Nelliyat 2005).

After exports started, the magnitude of pollution and environmen-tal degradation increased in Tiruppur area. In 1991, the Tiruppur Dyers’ Association formed a company, the Tiruppur Effl uent Treat-ment Company (Private) Ltd and initiated attempts towards the construction of effl uent treatment plants. Unfortunately, progress was negligible till 1996. Subsequently in 1997, following the order of the Madras High Court, industries decided to construct effl uent treatment plants. Currently, the units are treating their effl uents either through Individual Effl uent Treatment Plants (IETPs) or Common


Effl uent Treatment Plants (CETPs). Of the 702 units, 278 units are treating their effl uents through eight CETPs, while 424 units have IETPs (Nelliyat 2005).

For effl uent treatment, Rs 476.80 million (Rs 272.40 million by CETPs and Rs 204.40 million by IETPs) was spent as fi xed costs (One US dollar = Rs 45). In case of CETPs, the fi xed cost was highly subsidised by the government. Besides, Rs 311.80 million (Rs 118.40 million by CETPs and Rs 193.40 million by IETPs) was incurred as annual variable or running costs. The pollution abatement cost analysis revealed that the variable cost of pollution abatement is much higher than the annualised capital cost, both in the case of IETPs (86 per cent) and CETPs (73 per cent) (Nelliyat 2005).

Unfortunately, the present effl uent treatment system is inadequate for reducing TDS, particularly chlorides and sulphates. The physio-chemical treatment partially removes colour, Biochemical Oxygen Demand (BOD), Chemical Oxygen Demand (COD) and Total Suspended Solids (TSS) from the wastewater. The average TDS con-centration in the treated effl uents is as high as 6394 mg/l in IETPs and 6537 mg/l in CETPs, which is far higher than the standard 2100 mg/l set by the Tamil Nadu Pollution Control Board (TNPCB). The same is true of chloride, which averages 3290 mg/l in IETPs and 3127 mg/l in CETPs, whereas the standard set by TNPCB is 1000 mg/l. Since there is no subsidy for operation and maintenance cost, many industries are unwilling to operate their effl uent treatment plants. Besides, TNPCB did not take any serious action against those who violated the standard effl uent norms.

In 2007, the High Court insisted that industries follow ‘zero discharge’ for protecting the environment. Accordingly most of the units started preparations for installing reverse osmosis (RO) plants. However, the move met with little success. For processing units, the pollution abatement cost is a newly emerging cost of production and can either be met by increasing the price or by sacrifi cing the profi t margin or through a combination of both. Since the units are large in number, the competition is very high. Hence, industrialists have a general reluctance to allocate the pollution abatement cost to produc-tion, since any increase in the price may affect their business.


HEALTH IMPACTS OF TEXTILE PROCESSING AND HEALTH RISK ASSESSMENT IN TIRUPPUR AREA

The vapours and fumes of acids and chemicals used in textile pro-cessing impact the health of workers and damage the environment. The discharge effl uents cause lowering of dissolved oxygen, damag-ing aquatic life, and exposure to toxics affect the downstream water users.

The workers in the processing units are generally exposed to various types of chemical hazards. The health impact of chemical exposure is largely dependent on the exposure route and duration, concentration of chemicals used, and individual variability, that is health status and age. Since many of these processes such as mercerising, bleaching and dyeing depend on the desired fi nal product, workers’ exposure to chemicals depend on the individual processes undertaken by each unit, the technology used and the maintenance of the machines. For workers involved in fi nishing processes, it is expected that the most common routes of exposure to chemicals will be through dermal con-tact, inhalation or inadvertent ingestion of chemicals due to improper hygiene practices (SRMCRI 2004).

Hydrogen peroxide and sodium hydroxide (commonly used in fi n-ishing processes, i.e., desizing, bleaching, and mercerising) are known to irritate the skin, leading to contact dermatitis in low concentra-tions. During preparation of fi nishing operations, the solution bath is often heated to a high temperature. Conse quently, these chemicals are converted into vapours, thus increasing the risk to workers. Both hydrogen peroxide and sodium hydroxide are known to irritate the mucous membranes. Reactive dyes are the most common dye type used for cotton textile dyeing processes. Typical metals found in the reactive dye solution are nickel and copper. These metals are an integral part of the dye molecule, specifi cally used to enhance the colour of dyed cotton textiles. Therefore, exposure to these metals is a potential risk to worker health during the dyeing process.

Nickel compounds are known to cause contact allergic dermatitis, and are likely a nasal and lung carcinogen. Nickel compounds may also increase susceptibility to respiratory infections. Copper exposure at suffi ciently high concentrations is known to cause metal fume


fever, resulting in chills, muscle aches, nausea, fever and fatigue. Copper is also a respiratory irritant, leading to mucosal irritation of the mouth, eyes and nose (SRMCRI 2004). Table 13.1 provides details of chemicals used in various processing stages in textile industry and its health risks.

Generally, textile effl uents are characterised by high bacterial population, organic contents, volatility, salinity, chemical reactivity, photosensitivity and high pH (Rosa et al. 1999). A United Nation Environmental Programme study (UNEP 2001) said:

The trace constituents that are washed into effl uents such as dyes, oils, surfactants and other substances are of serious concern. Concentration will often be quite low but these substances may still present a residual health risk, especially if receiving waters are to be used downstream for drinking.

The organic priority pollutants expected to be found in textile effl uents are substituted phenols. The metal priority pollutants com-monly found in the textile effl uent are Zinc, Copper, Chromium, Lead, Cadmium and Nickel (Azeez 2001, Environment Canada 2003). If the heavy metals percolated into drinking water sources or get into the food chain, the health impact would be very serious (World Bank 1998). The possibilities of pesticide concentration in effl uents are high since they are substantially used for production of natural fi bres for example, cotton cultivation, and transferred to effl uents during wash-ing and scouring operations. Hence, wastewater should be checked for pesticides such as dichloro diphenyl trichloroethane (DDT) and poly chloro phenol (PCP) and for metals such as Mercury, Arsenic and Copper.

Environment Canada (2003) stated that the wet processing sector uses and discharges toxic elements like nonylphenol and its ethoxylates.

The physico-chemical analyses are not suffi cient to understand the integrated effects of complex chemical mixtures upon human health and environmental system and should be completed by eco-toxicological studies.

The above discussions explain the toxic nature of textile effl uents and the possible impact on health, if the effl uents contaminate the


Tab

le 1

3.1:

Che

mic

als

Use

d in

Var

ious

Pro

cess

ing

Stag

es in

Tex

tile

Ind

ustr

y an

d it

s H

ealt

h R

isks

Proc

ess

Che

mic

als U

sed

Impa

ct o

f Gas

eous

Em

issio

nsIm

pact

of E

ffl ue

nts

Des

izin

g En

zym

es o

r H2S

O4 f

or st

arch

, de

terg

ents

and

alk

ali f

or P

VA

an

d C

MC

May

cau

se b

loat

ing

and

Dia

rrho

ea.

Irrit

ant t

o ey

es a

nd sk

in

Hig

h B

OD

/CO

D, h

igh

tem

pera

ture

, siz

e im

purit

ies,

lubr

ican

ts, m

etal

s.

Scou

ring

NaO

H,N

a 2C

O3,

surf

acta

nts,

chlo

rinat

ed so

lven

ts

Non

-ioni

c de

terg

ents

may

cau

se b

loat

ing

and

Dia

rrho

ea, i

rrita

nt to

eye

s and

skin

Hig

h B

OD

and

tem

pera

ture

, ver

y hi

gh p

H, f

ats,

wax

es a

nd si

ze re

sidue

s ca

usin

g di

stur

banc

e to

aqu

atic

life

B

leac

hing

H

ypoc

hlor

ite H

ydro

gen

pero

xide

Ace

tic a

cid

Chl

orin

e ga

s is r

elea

sed

caus

ing

seve

re

irrita

tion

of re

spira

tory

trac

t and

eye

sLo

w to

mod

erat

e B

OD

, hig

h pH

and

te

mpe

ratu

re

Mer

ceriz

atio

n N

aOH

, sur

fact

ants

, aci

d,

liqui

d am

mon

ium

-

Ver

y hi

gh p

H a

nd d

issol

ved

solid

s, so

me

BO

D


Dye

ing

Dye

stuf

fs

Aux

iliar

ies

Red

ucta

nts

Oxi

dant

s (D

ye d

ust i

s an

impo

rtan

t so

urce

of p

ollu

tion)

Am

onia

is ir

ritat

ing

to th

e sk

in, e

yes,

nose

, thr

oat,

and

uppe

r res

pira

tory

sy

stem

. Bas

ic d

ye is

gen

eral

ly to

xic

(for

exa

mpl

e cr

ysta

l vio

let)

. Po

tass

ium

dic

hrom

ate

can

caus

e de

rmat

itis a

nd u

lcer

atio

n an

d it

is ca

rcin

ogen

ic.

Expo

sure

to d

ye d

ust t

hrou

ghbr

eath

ing

or sk

in c

an re

sult

in A

sthm

a,

Ecze

ma

and

seve

re a

llerg

ic re

actio

ns.

Hea

vy m

etal

s suc

h as

Cu

and

Cr

Car

cino

geni

c am

ines

T

oxic

com

poun

ds, f

or e

xam

ple

carr

iers

H

2SC

orro

sion,

Ir

ritan

t Fo

r woo

l dye

, hig

h B

OD

, pos

sibly

to

xic,

and

pH

low

Prin

ting

Dye

s (ac

ids o

r alk

alis)

, pi

gmen

ts, k

eros

ene,

bin

ders

, ot

her a

dditi

ves

Am

mon

ia X

ylen

es

Form

alde

hyde

cau

ses i

nten

se ir

ritat

ion

to e

yes a

nd n

ose

and

head

ache

s. It

is

carc

inog

enic

. K

eros

ene

caus

es n

ause

a, v

omiti

ng a

nd

coug

hing

, lea

ding

to re

spira

tory

pa

raly

sis.

Am

onia

vap

our i

s sev

ere

irrita

nt to

eye

s, ca

uses

vom

iting

, Dia

rrho

ea, s

wea

ting

and

coug

hing

. Hig

h co

ncen

trat

ion

can

caus

e re

spira

tory

arr

est

Hea

vy m

etal

s (to

xic)

Car

cino

geni

c Ir

ritan

ts

Fire

haz

ard

Hig

h B

OD

& C

OD

dep

endi

ng o

n ty

pe o

f thi

cken

er

Dist

urba

nce

of a

quat

ic li

fe, f

or

exam

ple

urea

and

pho

spha

te

Sour

ce:

Diff

eren

t sou

rces

.


drinking water and food chain—grain, fruits, vegetables irrigated with effl uents and fi sh grown in effl uent-contaminated water. Unfor-tunately, serious epidemiological analysis at pollution-affected areas are not enough, primarily due to the complexity in methodology and lack of reliable data. The following empirical studies give some idea on the health issues connected to water pollution caused by textile industry:

z Ullah et al. (2006) carried out a health assessment study at Kalliakori, a textile pollution affected area in Bangladesh. The water quality study revealed high alkaline concentration in the water. In order to understand health problems, focus group discussions and a survey of the community that lives in pollu-tion affected areas was carried out. Besides, detailed interviews among the healthcare professionals such as doctors, pharmacists, nurses, and so on were also conducted. The most common dis-eases reported in the area include diarrhoea and dysentery, skin diseases such as allergic conditions and itching, cold, respira-tory diseases and gastric ulcers. The problems of diarrhoea and dysentery are unlikely to be caused directly by the industrial effl uents as the result of microbial contaminants.

z Mathur et al. (2005) studied a dyeing and printing industrial cluster of Jaipur (capital of Rajasthan, a state in India). The study revealed that the effl uents contain highly toxic dyes, bleaching agents, salts, acids and alkalis. Heavy metals like Cadmium, Copper, Zinc, Chromium, and Iron are also found in the dye effl uents. Textile workers and residents were exposed to these effl uents. Hence the possible health risks were high.

z Rajaguru et al. (2002) conducted a laboratory study based on the groundwater samples collected from 12 locations from Tiruppur. The data indicated that the groundwater is contaminated with substances capable of inducing DNA damage in human cells. Therefore, direct or indirect exposure of this contaminant water may cause mutagenic/carcinogenic damage to exposed individuals.


z Govindarajalu (2003) studied the health status of 31 industrial-pollution-affected villages in Tiruppur area through three major health camps. A total of 1,120 villagers attended the camps. After medical investigations, it was found that 279 villagers or 24.9 per cent had symptoms of water-borne diseases. Health problems, such as skin allergies, respiratory infections, general allergies, gastritis and ulcers were the common complaints.

According to the medical practitioners at Tiruppur and the municipal health offi cer the increasing trend of water-borne diseases in Tiruppur area is due to the untreated and partially treated effl uents discharged by the textile units (Personal interviews 2004).

However, a detailed scientifi c study with an epidemiological survey by an interdisciplinary team is urgently required for substantiating the water pollution and health linkages, both occupational and environ-mental, in Tiruppur area. A majority of the people in Tiruppur are working in textile companies in unhygienic environments. In most of the processing units, workers do not take any precautionary mea-sures while handling chemicals and processing the fabric. Hence the occupational health hazards are also a serious concern. For people who are working in textile companies and living in Tiruppur, the disease exposure is from work environment as well as the living environment (Personal discussion with local people 2004).

Following are how textile industrial pollution causes health risks in Tiruppur:

Use of Contaminated Water for Drinking and Other Domestic Purpose

In Tiruppur town and the surrounding pollution-affected villages, people depend on groundwater for domestic purposes. The water supplied by the municipality and water board is not adequate for meeting the basic requirements. Generally, people spend huge sums of money for purchasing water from tankers. However, the poor people and slum-dwellers continue to depend on polluted groundwater for domestic purposes. The possibilities of inhaling the microbial and


chemical contaminants are high among such people. High TDS concentration in drinking water gives an obnoxious taste to the water and may affect the osmotic fl ow and movement of the fl uid.

Polluted Water Used for Food Crops

The toxic textile industry-related effl uents are used to grow food. Rosa et al. (1999) conducted a phyto-toxicity test to understand the toxic effect of untreated textile effl uents on plants. The study examined the effl uent-induced changes in germination rate and biomass of several plant species and came up with the conclusion that the effl uents could have important implications on the richness and distribution of plant species in an effl uent impacted zone. The study also recom-mended a detailed and appropriate phyto-toxicity test and extensive fi eld monitoring for understanding the exact intensity of the effl uent impact.

In the pollution affected area of Noyyal River, tanks and the down-stream reservoir (Orthapalayam) are the main source of irrigation. Earlier, when the sources were not contaminated, farmers depended on them. But now they are not in a position to cultivate most of the crops and the productivity has been reduced considerably. Still some farmers are using the contaminated surface and groundwater for irrigating food crops like banana, sugarcane, vegetables, groundnut, paddy, cereals, and slo on. Hence, the toxicity effects on the cultivated food item are of critical concern in public health perspective.

Fish Toxicity

Even though the river, tanks and reservoir are polluted, some infor-mal fi shing still takes place. Fish are caught and sold in the local and neighbouring markets. According to Azeez (2001):

Many dyes commonly used are known to have serious health impli-cations. Azo dyes, which were used widely, are now banned due to harmful properties including carcinogenesis. It is found that many species of fi sh survive in the Orthapalayam reservoir where all the chemical wastes from Tiruppur get collected. It is quite possible that the fi sh accumulate these chemicals which are later transferred to human beings who eat them.


Hence, fi sh toxicity study emphasising its bio-magnifi cation effects and health risks is also important.

POLITICAL ECONOMY AND GOVERNANCE ISSUES

Clearly after globalisation the export boom in Tiruppur led to serious damage to the surface and groundwater. To some extent the overall economic benefi t of the industry has undervalued the environmental cost. However, the environmental (including health) cost, borne by the downstream communities, who have no connection with the industries, is a major concern. Moreover, the physical environment—groundwater, soil, river, ponds and biodiversity—of the entire region may be losing its ecological value and undergoing irreversible changes. There are several reasons for the environmentally unsustainable industrial development of Tiruppur, which can broadly be classifi ed as market, policy, institutional and technological failures.

Market Failure

The processing units are part of the small scale sector and hence, pol-lution control appears unaffordable to them. In a competitive market, situation entrepreneurs have problems in transferring the burden of pollution abatement to consumers. The possibility for integrating the pollution abatement cost in the overall garment production in a decentralised cluster like Tiruppur is small. Currently the dyers have the full responsibility of environmental management. But they are relatively small players in comparison to the garment manufacturers or the exporters. Thus, it has not been possible to internalise the external cost of pollution, a classic case of market failure. Market at the inter-national level has also failed to provide a ‘premium’ for eco-friendly production which could have been an incentive to the industry. The concept of ‘green production/business’ has not infl uenced the Tiruppur industry. Eco-labelling considers only the product quality and not the environmental aspects related to manufacturing. The overseas importers and consumers are aware about the environmental problems, but their primary consideration is the market price. Cur-rently, they are not willing to pay more for the products manufactured in an eco-friendly manner with proper pollution management.


Policy Failure

Many of the industrial units in Tiruppur, which achieved substantial progress after globalisation, are in the cottage and small scale sector. This is partly due to the national industrial policies, which provide reservation of industries, like knitwear, under small scale industries (SSIs). Since SSIs do not have clean technologies, as well as modern pollution management, they are facing serious diffi culties in complying with domestic environmental regulations. Industrial policies do not take into account environmental repercussions. The policy decision of the TNPCB to permit units to put up their own IETPs has added to the workload of the Board. In a small scale cluster, all or at least majority of the units should have joined CETPs. But in Tiruppur, out of 702 units, only 278 are with CETPs.

Institutional Failure

The environmental management history of Tiruppur reveals the dif-fi culties faced by different institutions or actors like TNPCB, industrial organisations, non-governmental organisations (NGOs), local gov-ernment and the water resources organisations, in fi nding a solution to the problem. Otherwise, the environmental and health risks may not have reached this level. Currently, with the existing effl uent treatment facilities, industries are not meeting the TDS standards. Tiruppur Exporters’ Association (TEA), SITRA, AEPC, TC, South India Hosiery Manufacture Association (SIHMA) and the Tiruppur Dyers Association (TDA) are the major facilitators for industrial development in Tiruppur. Although TDA is trying to face the chal-lenge of pollution management, no serious attempt has been made by powerful organisations like TEA. Groups like TEA believe pol-lution management is essentially the dyers’ problem and exporters do not have any direct responsibility. Another disappointing aspect is the weak efforts of local NGOs and households. Generally, local people who depend on the industry are shortsighted and feel that any agitation against pollution might be a threat to the industry. A collaborative/integrate pollution management effort from industrial organisations, line/government department and local NGOs is so far lacking in Tiruppur.


Technological Failure

Most of the units use traditional methods of processing like winch which consume more water and chemicals as well as generate more effl uents. The introduction of Cleaner Production (CP) technology in the manufacturing process can substantially address the issue. The application of CP in textile industry might include a combination of soft fl ow machines, low salt dyes and membrane fi ltration. However, a large number of small units cannot afford CP technology.

CONCLUSION AND RECOMMENDATIONS Globalisation provides opportunities for developing countries to benefit from their comparative advantage in the production of natural resource-intensive products. In many countries it is SSIs that have made substantial progress after globalization. Clearly, SSIs have considerable problems in introducing modern and clean technologies of production as well as adequate pollution abatement technologies. Hence, these units encounter serious diffi culties in complying with domestic environmental regulations. Moreover, since the industries face stiff competition in international markets, they are reluctant to invest in pollution management, which may increase the price of the fi nal product.

The Indian textile sector witnessed substantial growth in exports after the economic globalisation. Simultaneously, most of the textile clusters also experienced severe environmental problems including health risks due to the disposal of effl uents and sludge. In Tiruppur, collective failure of markets, policy, institutions and technologies, has resulted in severe pollution and health risks.

Although in certain pollution affected areas, some preliminary attempts have been made to understand the health impacts, most of the studies lack adequate scientifi c investigation or epidemiological analysis. Merely checking health records, most of which is not main-tained properly, or conducting a perception survey in the pollution affected areas, is not enough. In areas affected by industrial pollution, the nature of pollutants and the related health impacts may vary substantially based on the type of industry and nature of effl uent. For example, even in the textile effl uents, characteristics would vary


based on the dyes used in the processing and its chemical composition (Personal interview with industrialists and dyeing masters 2004).

In brief, in areas affected by industrial pollution, unless a detailed imperial research is undertaken to identify and explain links between pollution and health impacts, the problem will not be adequately addressed. Hence, a serious attempt to understand the health impact of pollution with the help of medical researchers and other disciplin-ary experts is extremely important. These studies should consider the major pollutants which get exposed in human system, mode of exposure, potential physical health risks on different age-groups and socially vulnerable communities and its monetary costs, general awareness and preventive health care measures taken by the com-munities, public expenditure towards health care, and the defensive expenditure, such as costs for supplying protected water, incurred by the government, and so on.

Moreover, there is a need for immediate and strict policy initiative for preventing further waste disposal and eco-friendly textile process-ing. In this regard the following steps are urgently required:

z Strict Enforcement: The role of Pollution Control Board is critical in pollution management and it should strictly enforce all the pollution control regulations. The TDS standard should be enforced with respect to all the textile processing units after considering the cost of the environmental damage and health impacts that they may cause.

z Economic Instruments: Since industries do not meet the effl uent standard for TDS the introduction of economic instruments like effl uent taxes, fi nes or compensation to the affected parties could act as an important incentive towards pollution management. The burden of treatment cost, particularly the variable costs, is more for the smaller units. Hence the introduction of subsidies to small units for treatment will serve as an incentive towards the proper functioning of the plants.

z Cleaner Production (CP) Technologies: The introduction of CP technologies in the manufacturing process may be the only effective long-range solution for reducing the pollution prob-lems of textile industries and achieve sustainable development. Even though soft fl ow machines are capital intensive, they are


economical in the long run and also environment friendly. Adequate efforts from the concerned agencies are required towards the widespread application of CP in textile processing.

z Applications of Natural Dyes: Natural dyes are an eco-friendly substitute of synthetic dyes, and are less harmful. Adequate research is needed towards the economical application of natural dyes in the processing of different textiles.

z Integrated Stakeholders Efforts: All government departments concerned with the development of textile industry and envi-ronmental aspects in Tiruppur should come forward and work together to solve the environmental problems of Tiruppur. Moreover, the local administration and NGOs need to create more awareness about the seriousness of environmental and health damage in Tiruppur area.

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———. 2008. ‘Issues of Textile Wastewater from Dyeing and Bleaching Indus-tries in Tiruppur’, in the proceedings of the workshop on Evolving a Model for Integrated Water Supply: Waste Water Effl uent Management to Towns with Small Manufacturing Units in South East Asia’, 19 November, Karunya University, Coimbatore.

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Nelliyat, P. 2005. ‘Industrial Growth and Environmental Degradation: A Case Study of Industrial Pollution in Tiruppur’, Ph.D. Thesis, University of Madras, Chennai.

Rajaguru, P., L. Vidya, B. Baskarasethupathi, P. Kumarb, M. Palanivel, and K. Kalaiselvi. 2002. ‘Genotoxicity Evaluation of Polluted Ground Water in Human Peripheral Blood Lymphocytes Using the Comet Assay’, Mutation Research, 517:29–37. Available online at www.elsevier.com/locate/gentox. Com-munity address: www.elsevier.com/locate/mutres.

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Shiklomanor, I. A. 2000. ‘World Water Resources and their Use’. St. Petersburg: UNESCO and State Hydrological Institute.

SRMCRI. 2004. ‘Job-exposure-health Profi les for Textile Units in Tamil Nadu: A Baseline Evaluation of the Work Environment and Worker’s Health Status in Cotton Processing Mills’. Final Report, Department of Environmental Health Engineering, Sri Ramachandra Medical College and Research Institute, Chennai.

Ullah, A.N.Z., A. Clemett, N. Chowdhury, M. Chadwick, T. Huq, and R. Sultana. 2006. ‘Human Health and Industrial Pollution in Bangladesh’, Report, Stockholm Environmental Institute. Sweden.

UNEP. 2001. ‘The Textile Industry and the Environment’, UNEP Report on Industry and Environment, United Nations Environment Programme, Paris.

UNIDO. 2003. ‘Water and Industry’, in Water, a Shared Responsibility: The United Nations World Development Report 2’, United Nations Industrial Development Organization.

WHO. 2003. ‘Basic Needs and the Right to Health’, in ‘Water a Shared Responsibil-ity: The United Nations World Development Report 2’. Geneva: World Health Organization.

World Bank. 1998. Pollution Prevention and Abatement Handbook. Washington, D.C.: The World Bank.

———. 2003. World Development Indicators. New York: World Bank.

14

Impact of Mining on Water and Human Health

A Case Study of Baitarani River Ecosystem in Orissa

SARMISTHA PATTANAIK1

INTRODUCTION INDIA IS A major mineral producer in the world (Davis 2007) with a wealth of minerals like Coal, Iron ore, Manganese, Mica, Bauxite, chromites and diamonds. The mineral industry in India has played a prominent role in gearing the economy and is considered the backbone of industrial development and a source of valuable foreign exchange. The country has a well-developed mining sector with over 20,000 known mineral deposits (TERI 2001). However, like any other devel-oping region with large mineral deposits, India is also confronted with the challenge of striking the right balance between exploiting mineral resources for economic prosperity and safeguarding environmental stability and social welfare.

Most of Orissa’s mineral deposits are in forests inhabited by tribal populations and harbour rich biodiversity. Mineral extraction, there-fore, has adversely affected forest ecosystems and the forest population (Sills et al). However, the mineral sector is perceived to have failed to alleviate poverty in the region. Thus, the impact of mining upon natural ecosystems, biodiversity, tribal livelihoods and human health has become a source of concern and confl ict in Orissa.

1 I am thankful to SHRISTI, an NGO in Bhubaneswar, Orissa, for extending its support during my fi eld survey in 2007. My special thanks to Pranab Chaudhury, the Baitarani Basin’s co-ordinator, whose initial support and encouragement helped me to look at the problem more vigorously. I would also like to thank Samarjit Barik, my fi eld assistant, for helping me throughout my village survey and especially creating rapport with the tribal and primitive tribal groups in the interior areas.

312 Sarmistha Pattanaik

This chapter discusses the results of a study conducted in 2007 in the Baitarani River ecosystem in Keonjar district of Orissa. The chapter is divided into fi ve sections covering different aspects. It details the impact on water and health of the local community, the method-ology, sampling procedure and sources of data used in the research, the major fi ndings based on the objectives and research questions and fi nally, observations of the research along with recommendations. This chapter not only examines the environmental aspects but also the social cost of sponge and iron ore mining activities in the region.

HARMFUL EFFECTS OF MINING The Mineral Policy in the 1980s opened the gates of Indian mineral industry to domestic and foreign investment (TERI 2001). Mining activities around the world have been accompanied by land expro-priation and environmental degradation that harm the livelihoods and health of local communities (Karyn et al. 2002). Mining can acidify soil and water, increase toxic chemical availability and increase siltation of water and leaf surfaces. These effects, in turn, are known to decrease water availability, reduce plant growth, and eventually harm the wildlife and reduce ecological diversity (Ripley et al. 1996, Saxena et al. 2002).

Orissa holds a key position as a mineral producer. It leads the country in the production of iron ore, with a share of 28 per cent as per analysis of data from Anon (2006). Spurred by the spiral demand for steel in the international market, several conglomerates came for-ward in the 1980s to set up metal production units, exploiting the iron ore resource of the state to produce steel. Steel industry consumes large volumes of water. The Government of Orissa signed about 50 Memoranda of Understanding (MoUs) with private companies to produce more than 70 metric tonne (MT) of steel per annum. The government also hiked its annual steel production that required about 2,250 MT of iron ore until 2020, compared to the current state production of only about 2 MT (CSE 2008). The CSE report stated that based on the government’s current steel plant projects, it would require at least 527 million cubic metre of freshwater annually which will be drawn from Baitarani River, besides tapping the Mahanadi

Impact of Mining on Water and Human Health 313

and Brahmani rivers. The river, its ecosystem and basin catchments, all are today under threat.

There areno estimates about the total amount of water used by metallic mineral mines in India. However, some conclusions can be derived from the water consumption data of major mines. Average water consumption, excluding domestic consumption, at the iron ore mines of Tata Steel in Jharkhand and Joda East in Keonjhar district in Orissa, is about 600 litre per ton of iron ore (CSE 2008). Besides consuming water, mines also deplete groundwater by breach-ing the groundwater table in areas surrounding the mines. Breaching of the groundwater table creates a large amount of depression in the groundwater regime. As a result, the groundwater levels are lowered in the surrounding areas.

About 40 per cent of the large captive limestone mines ion India have breached the groundwater table (CSE 2008). The Talcher coalfi elds in Orissa, with their huge opencast mines, have dried up local ponds and wells. Large and deep opencast mines exercise their own impact on the hydrological regime of the region. Deforestation over mine leaseholds and changes in the watershed characteristics have affected water fl ows in streams in mining regions. The fl ow has dwindled and perennial streams have receded. This effect is most pronounced in the case of mountain-top mining, particularly in Orissa. People of Orissa have opposed bauxite mining on the hills of Lanjigarh and iron ore mining on the hills of Baula in Mayurbhanj since 2003 and Khanadhar in Keonjhar since 2005 because of Pohang Steel Company [POSCO]) fearing it will dry up the mountain streams (Dash and Samal 2008). As a result of the agitation against Vedanta project in Lanjigarh, environmentalists and activists fi led petitions before the Central Empowered Committee (CEC) of the Supreme Court in 2005. Based on the observations, the CEC recommended to the Supreme Court that use of the forest land in an ecologically sensitive area like the Niyamgiri Hills should not be permitted.

The present study was undertaken in the state of Orissa where large and small scale iron ore mines and steel industries have caused massive environmental problems by contaminating the water of the Baitarani River and its perennial streams. The process of industrialisation has adversely impacted the health of the local community living adjacent to the mining areas.


WATER USED IN MINERAL-BASED INDUSTRIES IN ORISSA

In 2006, Biswajit Mohanty, an environmental activist and secretary, Wildlife Society of Orissa, declared, ‘The industrialisation boom will result in massive environmental degradation since the local environ-ment has limited ‘carrying capacity’ to absorb and assimilate effl uents and wastes produced from such gigantic production facilities’ (Hindu Business Line 2006). His concerns have come true.

Orissa has been considered a water-surplus state. Although the state occupies only 4 per cent of India’s total geographical area, it has 11 per cent of the country’s total water resources (CSE 2008). But the water-plenty picture of Orissa has severely been tainted due to the operations of water consuming industries. The target of pro-ducing more than 70 MT of steel every year has begun to show its effects—watersheds and rivers in Orissa are under threat and changes in hydrology imminent. The hilly terrain of the state is home to many natural springs that give birth to many rivers. Mining in this terrain has completely destroyed the springs.

Water Consumption by Industries

Most mineral-based industries in India, particularly in Orissa, are located close to their main inputs, the minerals. Thus, the pressure on local water resources comes not only from mining, but also from related industries. For instance earlier River Brahmani, the second largest river in Orissa, used to provide plenty of water to the region which sustained a predominantly agrarian economy. However, once mining started, industries started guzzling more than 56 per cent of the river water. They also polluted the water by discharging their effl uents into it. Today, the Talcher–Anugul region is considered a living desert.

Groundwater is equally stressed in the region. Ten billion litres of groundwater is pumped out every year in the coalfi elds of Talcher, drying up aquifers in an area of 1,000 sq km (Khatua and Stanley 2006). The steel industries are the highest consumers of water; every tonne of steel requires about 10–80 tonnes of water. Altogether, the sector consumes around 516 MT of water every year (CSE 2008).


Industries Pollute Water

The Orissa State of Environment Report, published by the Orissa State Pollution Control Board (OSPCB), Bhubaneshwar, classifi es areas based on their pollution potential. According to the report, Zone 1 includes districts like Keonjhar and Sundergarh, which are rich in Iron and Manganese ore but face extensive pollution of rivers and rivulets. During the rainy season, water in the rivers turns red and the level of total suspended solids goes up to 1,000 mg/l (CSE 2008).

In 2007, the Supreme Court sought a comprehensive report from the Ministry of Environment and Forests, Government of India on the following aspects:

1. The extent of forest lands involved in mining in the districts of Koraput and Kalahandi in Orissa.

2. The number of mining applications pending and the possible impact on forests, ecology and tribals, if these minings are allowed.

3. Safeguards to be imposed while giving mining licenses in these areas.

In addition to this the report on ‘Assessment of environmental, economic and social impacts of bauxite mining and alumina process-ing’ in Kashipur and Kalahandi, submitted by the Ministry of Envi-ronment and Forests to the Supreme Court of India (Civil Original Jurisdiction, Writ Petition (C) NO. 549 of 2007) on 5 October 2007, highlighted the hydro-geology of bauxite bearing areas, stating the close relation of bauxite bearing areas with the water regime.2 The report on Assessment of environmental, economic and social impacts of bauxite mining and alumina processing in Kashipur and Kalahandi in Orissa prepared by TARU in June 1996 highlighted the hydro-geology of bauxite bearing areas, stating their close relation with the water regime. It specifi cally mentioned that:

2 Refer to the Supreme Court Civil Original Jurisdiction, Writ Petition (C). No. 549 of 2007, in the matter of Sidhartha Nayak, State of Orissa and Others Vs Petitioner/Respondents.


The presence of innumerable perennial springs (and often spring lines) along the rim of the laterite plateau indicates that the recharge does not take place in suffi cient quantities. The grass cover growing in the beginning of the season ensures that the water is not allowed to fl ow away freely and lost. Thus, it is unfortunate that the MoEF granted clearance to the mining projects in Orissa before many critical aspects of the project were confi rmed!

Health Impact on Local Community

A majority of the health problems in mining regions are caused due to unchecked pollution and high levels of toxicity, mine tailings and mine disasters. Health and even safety problems vary depending on the mineral being mined, technology used, type of mining in operation, that is opencast or underground, and the size of the operations. The land, water bodies, air and environment are polluted due to constant release of chemical wastes, dust generated by blasting and excavation, and the dumping of mine wastes and over-burden in the surrounding lands and rivers.

THE PRESENT STUDY

Study Area

The study area of Baitarani River ecosystem in Keonjhar district is an ecologically sensitive area. The Baitarani is one of the six major rivers of Orissa, the others being Mahanadi, Brahmani, Subarnarekha, Budhabalanga and Rushikulya) and covers 8 per cent of the state’s geographical area spread across 42 blocks of eight out of total 30 districts in the state. It originates from Guptaganga hills in Gonasika at an elevation of 900 m above Mean Sea Level (MSL). Its basin comprises of a major portion of Keonjhar, Bhadrak, Mayurbhanj and Jajpur districts and a small portion of Kendrapada, Sundergarh, Balasore and Anugul districts. An area of 736 sq. km lies in the state of Jharkhand. The river travels a distance of 365 km before joining the Bay of Bengal (Map 14.1).

Physiographically, the Baitarani basin is divided into three zones:

Impact of Mining on Water and Human Health 317M

ap 1

4.1:

P

hysi

ogra

phic

Div

isio

n of

Bai

tara

ni B

asin


1. The Northern Highlands (upper catchments) covering parts of Keonjhar, Mayurbhanj, Anugul and Sundergarh districts.

2. The Central Table Land (middle reach) covering parts of Keonjhar and Jajpur districts.

3. The Coastal Plains (lower reach) covering parts of Bhadrkh, Jajpur, Kendrapada and Balasore districts.

All the mines are located in the districts of Keonjhar, Jajpur, Mayurbhanj, Anugul and Sundergarh, covering the upper catchments of Baitarani basin. The mineral deposits constitute Coal, Bauxite, Quartz and Quarzite, Iron ore, Manganese and Chromite. There are altogether 186 working mines stretching over an area of 47,338.5 hectares.

KEONJHAR DISTRICT

Within the state of Orissa, Keonjhar district was selected for the study because of the concentration of iron ore mines in different blocks of the district, as well as many small and big steel and sponge industries in the town itself. Figure 14.1 highlights the bigger areas of mines dominated in the district.

For all its mineral wealth, Orissa performs very poorly in terms of human development indicators. The state has a Human Development Index (HDI) of 0.404 (GoO 2004). India ranks 134th out of 182 countries in the world, with the HDI estimated at 0.612, based on 2007 data according to the United Nations Development Programme (UNDP) report of 2009. However, as per the Economic Survey of Orissa Report 2008–09, Orissa ranks fi rst in poverty in India. (GoO 2008–09) Taking into account theavailability, access and absorp-tion of food, Orissa has been put in the category of ‘severely food insecure’ regions. The government also agrees that the food insecurity is due to a ‘vulnerable rural population with poor livelihood access’ (CSE 2008).

Except Jajpur and Anugul, most of the heavy mining districts of Orissa are tribal dominated. In Sundergarh, Koraput and Mayurbhanj,


Figure 14.1: Small Iron Ore Mines in Keonjhar

Sources: CSE (2008), Murthy (2006).

tribals account for more than 50 per cent of the population while in Keonjhar more than 44 per cent of the population is from the tribal community (Table 14.1). Infl ux of outsiders due to large-scale mining in Anugul and Jajpur has reduced the tribals to a minority in their own land.

It is obvious that the wealth and prosperity from mining has not reached the people in the districts mentioned in Table 14.1. Keonjhar ranks 30th in the list of the most backward districts in Orissa. Others are ranked way below; Sundergarh is 18 and Koraput 10. The per capita income in the mineral-rich districts is the lowest in Jajpur, just Rs 4,468 (less than $ 100). In the coal-rich districts like Anugul and Jharsuguda the per capita income is higher, Rs 10,877 ($ 233) and Rs 11,210 ($ 240), respectively.

Overall statistics indicate that the income from mineral extraction rarely benefi ts the regions from where these minerals are sourced. In fact, poverty is increasing in many of these districts. Some districts have gained probably because of higher employment provided by coal mining, but it has still not resulted in the overall food security, livelihood access or better health indicators.


Tab

le 1

4.1:

The

Min

ing

Dis

tric

ts in

Ori

ssa:

Hum

an D

evel

opm

ent I

ndic

ator

s

Dist

rict

T

riba

l Pop

ulat

ion

(Per

cent

age o

f Tot

al)

Rank

ing

Amon

g 15

0 Ba

ckw

ard

Dist

rict

sH

uman

Dev

elopm

ent

Inde

xLi

tera

cy R

ate

Per C

apita

Inco

me

(Rs)

1997

–98

Perc

enta

ge o

f Po

pula

tion

Und

er

BPL

Jajp

ur

7.4

136

22/3

072

.19

4,46

8N

AK

eonj

har

44.5

230

24/3

059

.75

5,28

661

.92

Sund

erga

rh

50.7

418

4/30

65.2

26,

823

36.4

8A

nugu

l 11

.68

106

6/30

69.4

10,8

77N

AK

orap

ut

50.6

710

27/3

036

.25,

148

78.6

5Jh

arsu

guda

31

.88

672/

3071

.47

11,2

10N

AM

ayur

bhan

j 57

.87

159/

3052

.43

4,29

768

.42

Oris

sa23

90%

∗–

50.9

7–

48.0

1

Sour

ce:

GoO

(200

4).

Not

e: C

rude

birt

h ra

te is

the

num

ber o

f birt

hs p

er th

ousa

nd p

eopl

e. T

wen

ty se

ven

out o

f 30

dist

ricts

are

in th

e ba

ckw

ard

list.


Land and Forest in the Keonjhar District

One of the most severe impacts of mining has been the changes it has brought to Orissa’s land use patterns and concurrently, its landscape. The lands taken for mining in Orissa have either been forest land, agricultural fi elds or common (grazing) land. Forests have especially borne the brunt of mining. While mining and mineral industry occupies just 0.64 per cent of the total geographical area in Orissa (Vasundhara 2006), most of the mineral deposits are in regions with forest cover. Nearly 39 per cent of the land area in Keonjhar is forest. Mining has wreaked havoc in these forests.

Figure 14.1 shows that Keonjhar district is the only district which produces the maximum amount of iron ore in the state compared to other districts (CSE 2008). Estimated as the source of almost 35 per cent of India’s total reserves of haematite, Orissa produced more than 46 million tonnes of iron ore in 2004–05 of which at least three quarters came from Keonjhar alone. Out of the three major mining districts of Orissa, Keonjhar, Sundergarh and Mayurbhanj, 32 per cent of the land under mining is located in Keonjhar district alone. Almost all of it was, and still is, carted away in trucks from the 119 mines of Keonjhar district (Frontline 2007). The trucks move north from Joda to the Jharkhand border where they supply iron ore to Jharkhand’s rapidly expanding steel industry and northwest to Haldia port. But the majority move south through Keonjhar town towards Cuttack and cut through to Paradip Port, from where the ore is shipped in containers to China, one of the few countries that have a bigger appetite for steel than India.As many as 64 sponge iron units in Keonjhar and Sundergarh districts have destroyed drinking water sources and agricultural fi elds (Das 2005).

According to the estimates of Orissa’s Department of Forests and Environment, 31,780 ha of forest land was diverted in Orissa for differ-ent projects, including mining, between 1980 and 2005 (CSE 2008). Mining alone accounted for half of the forest land diverted in the state, 15,386 ha. Table 14.2 shows the land use change in Keonjhar Sadar block within 15 years of mining between 1989 and 2004 with forest land reduced to half of its original size.


Methodology

The study was carried out during April−May 2007 in several sites of upper and middle catchments of the Baitarani Basin in Keonjhar district. The randomly selected blocks were Jhumpura, Bansapala and Hadagarh. Two villages were studied from each block. Thus data was collected from a stratifi ed random sample of 30 households in six villages. Information on demography, socioeconomic background of the households, dependence on agriculture, forest, health, perceptions of change in local environment, particularly on water resources, were elicited during the interviews. The greatest concern in the fi eld study was on environmental health caused due to degradation of water qual-ity, water shortages and non-availability of the traditional livelihoods central to the local tribal community in the mining belt.

Before discussing the various adverse health effects, it is perti-nent to know about the variables chosen for mine exposures, water pollution and other elementary aspects of resources in this study and how those elements fall and are perceived within the village vicinity.

This study is based on an analysis of local environmental and social impacts of mines in Orissa, especially on water and human health. The analysis combines information collected through household surveys, location of mines and villages, census data and data from Government of India (GoI) as well as the Directorate of Mines and OSPCB. It also examined secondary literature surveys to examine the impact of iron ore mines on water resource and local livelihoods in Keonjhar district with an effect to human health. Apart from the above data, NGOs

Table 14.2: Land Use Changes in Keonjhar Sadar Block

Land use Area in 1989 (ha) Area in 2004 (ha)

Habitat 2,822.02 3,642.86Agriculture 36,282.00 35,452.14Forest 12,837.99 7,576.63Wasteland 4,177.00 6,280.43Mining 755.54 77.76Water body 1,089.64 1,054.10

Source: Srivastav et al. (2006: 48) .


like Vasundhara3 and Shristi 4 also provided information on various aspects of mining and biodiversity (Table 14.3).

Sampling Procedure and Various Profi les of the Surveyed Households

Among the three blocks selected for the study, Jhumpura and Bansapala have high concentration of mines while Hadagarh is covered with dense forest and hills. Mining activities there is concentrated on the eastern side only. Further, this block has been affected not only by Boula chromite mines also. A few villages in this block have been affected due to displacement, rehabilitation and resettlement caused by dam construction on Salandi River, one of the major tributaries of Baitarani (Table 14.4).

The sample villages from Bansapala block, except Hadagarh and Jhumpura, are within 4 to 5 km of the closest iron ore mine. Simi-larly, as for Jhumpura and Bansapala blocks, industries such as steel, sponge iron and pig iron are located within 5 km buffer. Among the six sample villages, except Gonasika in Bansapala block, all others have tribal populations. The households studied in Gonasika village are of Juangs, under Primitive Tribal Group (PTG).

FINDINGS OF THE STUDY

Negative Impacts from Iron Ore Mining and Sponge Iron Industries on Water Regime

The presence of iron ore mines and sponge iron and steel industries have adversely impacted the local community of the upper catchments

3 ‘Vasundhara’ (http://www.vasundharaorissa.org) is a research and policy advo-cacy group located in Bhubaneswar working on environmental conservation and sustainable livelihood issues.

4 SHRITI, a development organisation in Bhubaneswar (www.baitarani.org/about-sristi.htm) works on rural development in NRM, focuses on micro fi nance and access to preventive health practices, livelihood issues and micro level development as its major thrust areas for impacting change and development in the villages of Orissa. In 2006 the organisation launched an innovative river basin management initiative in the Baitarani River Basin.


Table 14.3: Defi nitions of Mine Exposure, Water, Forest and Health Impact Variables

Variable Description

Mine exposure Mine exposure is defi ned as a function of distance to mines: villages closer to mines have higher exposure to mining activity. All the sample villages fall within the Peripheral Development Zone of 50 km from the mining area.

Water pollution Water gets polluted due to various mining activities in the villages. The industrial wastes are dumped into the nallas (tributaries of Baitarani) by the iron and sponge industries in the region, the count of ‘yes’ responses collected from the respondents in the studied villages.

Acute drinking water problem/water shortages

Shortage of water in agricultural fi elds, loss of productivity of land; count of ‘yes’ responses from the total no. of villages.

Deforestation due to mining Impact of mining on environment causes deforestation; count of ‘yes’ responses from the total no. of villages.

Employment in mines Number of people among the sample households employed in mines and industries; count of ‘yes’ responses from the total no. of villages.

More income from mining jobs (those displaced and got job in the mining area)

Impact of mines on living condition—increased household income; count of ‘yes’ responses by the respondents from total no. of villages

Poor health condition and health hazards in mining areas due to exposure to open cast mining.

Impact of mining and industries on living conditions— increased health problems; count of ‘yes’ responses by the respondents from total no. of villages

Source: Author’s fi eld survey, April−May 2007.1

1 Most of the variables in this Table have been derived from the household survey which includes the villages that represent forest resource conditions, access to forest and water sources which refl ects information from community survey through focus group discussions and direct interviews with some key informants, such as village headman, a tribal leader,


of Baitarani River Basin by disrupting their social structures and production systems. Table 14.5 highlights the community’s response about the environmental problems related to water and forest, and how the situation has been changed over time.

Impact of Iron Ore Mining on Socioeconomic and Human Health Aspects

Communities surrounding mine sites in upper catchments of Keonjhar district are forced to consume contaminated water from Baitarani river and its perennial streams as well as from wells and bore pumps. The water is contaminated due to poorly-treated or non-treated chemical wastes and debris, created by the mining companies, that seeps into the groundwater and soil. As a result, the communities, mainly trib-als, suffer from many water-related diseases like marked irritation of the respiratory tract, nasal septum ulcers and also irritant dermatitis rhinitis, bronchospasm and pneumonia. Children are usually seen with sores all over their bodies. During the fi eld survey it was observed that women and children who do not work in the mines are constantly exposed to various respiratory illnesses after they inhale the dust from the mines. They are also vulnerable to skin diseases and experience malfunctioning of various sensory organs. Women also reported nega-tive impact on their reproductive health.

For economic reasons, women have no choice but to expose themselves and their children to severe health risks. Women are more susceptible to water pollution as they are more in contact with water

Table 14.4: Sample Villages Surveyed in Keonjhar District

Name of Number of Households

Total Sample

Households

Whether Close to Mines (within 5 km Buffer)

Whether Close to Industry (Within 5 km Buffer)

Block VillageJhumpura Nuasahi 5 10 No Yes

Palaspanga 5 No YesBansapala Gonasika 5 15 Yes Partly

Suakathi 5 Yes NoDanla 5 Yes No

Hadagarh Sankatapalia 5 5 No No

Source: Author’s fi eld survey, April−May 2007.


Tab

le 1

4.5:

P

erce

ntag

e of

Res

pons

es o

n M

ine

Expo

sure

and

Env

iron

men

t

Num

ber o

f V

illag

esN

umbe

r of

Hou

seho

lds

Num

ber a

nd P

erce

ntag

e of R

espo

nses

from

Hou

seho

lds o

n

Envi

ronm

enta

l Pro

blem

s (W

ater

Sou

rces

) Cau

sed

Due

to M

inin

g an

d In

dustr

ies

Def

ores

tatio

nW

ater

Pol

lutio

nPo

or W

ater

Q

ualit

yAc

ute D

rink

ing

Wat

er

Prob

lem/W

ater

Sho

rtag

eLo

ss of

Pro

duct

ivity

of

Land

and

Agr

icul

ture

630

27 (9

0%)

25 (8

3%)

28 (9

3%)

29 (9

7%)

28 (9

3%)

Sour

ce:

Aut

hor’s

fi el

d su

rvey

, Apr

il–M

ay 2

007.


sources while performing household chores. Noise and dust pollution affects women the most during pregnancy.

The communities in the mining-affected areas have no alternative but to drink the water of the wells provided by miners. This water has a foul taste, is red in colour and very fi lthy. Areas of large-scale iron ore mining in Keonjhar district and other nearby districts are facing acute scarcity of water, mainly in summer and winter seasons (Table 14.5). Dug wells generally dry up in these two seasons. Natural drainage system is obstructed and diverted due to dumping and expansion of opencast mines. The study witnessed 87 per cent of households reporting various health problems and poor health hazards (Table 14.6) due to the impact of mining and industries. The study found almost every family in the local community suffered from several illnesses, such as respiratory problems, silicosis, tuberculosis and arthritis due to direct exposure to mining. Infant mortality rates have increased and there are many cases (26) where reproductive health of women suffered leading to a rise in domestic-social problems.

The forest cover eventually degenerates in all mining regions, including Orissa, both due to mining operations and new populations settling down on the fringes. For the forest dwelling community—the Juangs, one of the primitive tribal groups of the Keonjhar district in Gonasika village; Mundas of Jhumpura; Bhuinyas of Bansapala block and other tribals of Hadagarh—the main source of cash is the forest wealth, which they collect and sell in the village markets. After selling the produce, the women purchase food and other household items from the market and are in a position to save during seasons when the forest produce collected is abundant. It is from this income that they meet their medical expenses, purchase cloths for themselves and their children and invest in agricultural needs. But today, the loss of trad-itional rights over land and forests has contributed to the deterioration of women’s health status. Besides, the only source to healthcare for women, the forest rich in medicinal plants, is no more accessible to them.

WHAT NEEDS TO BE DONE

Looking at the acute scarcity and continuous decline in the water sources in Orissa and elsewhere in the country, an effective national water use plan through widespread participatory process should be


Tab

le 1

4.6:

R

espo

nses

on

Empl

oym

ent,

Inco

me,

Hea

lth

Impa

ct a

nd P

hysi

cal D

ispl

acem

ent

Num

ber o

f vi

llage

sN

umbe

r of

Hou

seho

lds

Resp

onse

s on

Empl

oym

ent

in M

ines

/Indu

strie

s

Com

pari

son

of

Inco

me b

etw

eenm

ine

and

Indu

strie

sPo

or H

ealth

/H

ealth

Haz

ards

Phys

ical

Disp

lace

men

t du

e to

Min

ing

and

Dam

Con

struc

tion

in

Mid

dle C

atch

men

tsRe

habi

litat

ion

and

Rese

ttlem

ent

630

12 (4

0%)

Nil

26 (8

7%)

22 (7

4%)

10 (3

4%)

Sour

ce:

Aut

hor’s

fi el

d su

rvey

, Apr

il–M

ay 2

007.

Not

e: R

ehab

ilita

tion

is se

en i

n tw

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evolved at the earliest. Agrawal and Narain (2001) give a clear mes-sage for the thirsty times ahead, ‘Water must be made everybody’s business’. An effective wateruse plan, along with the sector reforms of mining areas are the primary concern to counter the negative impacts of excess mining and its adverse effect on water sources and community health. There are numerous alternatives for reducing the negative health impacts and increasing the positive impacts of mining on the overall well-being of local community. This could be successful only through a combined and concerted effort from the government, companies and NGOs working with the community.

The state needs to be responsible for comprehensive formulation and implementation of policies related to promotion of sustainability of mining and mineral industry in India. In this context, a viable capacity building training for improved environmental management approach is necessary to achieve the goal of sustaining mining and mineral industry in India while simultaneously repairing local liveli-hoods of affected communities. Further, the inter-related nature of the social, health and environmental impacts of mining should be recognised and measures undertaken to mitigate such impacts in Keonjhar district. Nonetheless, an effective Environmental Manage-ment Plan (EMP) approach for systematically managing the ongoing environmental, social and health impacts of private and public sector industrial mining operations is strongly recommended.

Communities living close to the mining areas needs to demand a healthy and productive life in harmony with nature. If mining has to take place, the policy seriously ensures improvement on the work safety, security and sustainability of mining workers; the community demand safety of themselves and modern materials by modern instru-ments and tools that should be implemented to make the mining operation safe and less hazardous. Mining projects sanctioned should be on the policy of people-centred approach rather than market-centred approach. The community demands implemention of pollution prevention of mining activities in relation to processing, practices, material, products or energy that avoid or minimise the creation of pol-lutants and waste without creating new risks to the local community’s health and environment. The indigenous tribals and the local commu-nity have a vital role in the environment and mineral wealth of the areas; hence, their concern lies on the management and the development


of such mineral wealth that should be recognised through their knowledge about traditional practices. In fact, they demand that their identity, culture and interest to enable effective participation in the achievement of sustainable mining development should be supported by the state.

Promoting Development through Sustainable Mining Policy

CSE (2008) points out that mining cannot be sustainable or truly environment-friendly, because (i) all ore bodies are finite and non-renewable, and (ii) because even the best managed mines leave ‘environmental footprints’. However, the report concedes that mining and minerals are necessary. Chandra Bhushan, Associate Director of CSE says, ‘The issue is not whether mining should be undertaken or not. Rather, it is about how and where it should be undertaken. It is about ensuring that mining is conducted in an environmentally and socially acceptable manner’ (Infochange India News 2008).

The Environmental Impact Assessment (EIA) process in India is fl awed. Under clearance procedures, a public hearing is essential. But there is not a single case in Orissa where government regulators have rejected mining when the people objected. In fact, in most cases, renewal of mining leases has become a mere formality. No cases are fi led by the OSPCB where mining does not meet prescribed regula-tions. This suggests a complete breakdown of oversight procedures, essential for ‘sustainable’ mining. One of the necessary reforms recom-mended towards sustainable development in mining area in Orissa is granting mineral rights to tribals.

Mining from the health perspective in Orissa in general, and India in particular, has to address human health. Increase in health hazards and degeneration of the condition of local people, including women and children in Orissa, is one of the most adverse impacts of mining. The challenges are many in this area such as exposure of people to mine disasters and mine pollution as well as to the reduction in qual-ity of life due to denial of access to food security, natural resources and livelihoods. This case study in Orissa shows how these factors pose a threat to the well being and survival of the local people in the affected areas.

None of the existing legislations in India have provided any justice to communities suffering from health problems due to mining in


Orissa. Hence, occupational health issues of the local mine workers and communities living in the mining area need to be addressed urgently. No proper medical records are maintained or no health check-ups conducted either by the companies or governments. Moreover, occupational illnesses are suppressed and workers are promptly retrenched when health problems are detected. Mining enforces a non-agricultural system on the local people, thereby alienating them from their natural livelihood and threatening their food security, rights over natural resources and eventually causing deterioration in their health status. Here the issue arises how governments, policymakers and civil society groups defi ne and implement development and human growth vis-à-vis economic programmes from a health perspective.

To conclude, looking at all these challenges and issues, the need of the hour is for the government to go for setting up effective monitor-ing mechanisms for safeguarding the ecologically sensitive areas in the region impacted by existing mining activities or likely to be impacted by future ones. It also needs to ensure better health and safety of local community in mining regions not only in Keonjhar and other worst affected mining regions of the state but in other mining affected regions in the whole India.

REFERENCES

Agarwal, A, S. Narain, and I. Khurana. 2001. (eds) Making Water Everybody’s Business: Practice and Policy of Water Harvesting. New Delhi: Centre for Science and Environment.

Anon, 2005. Corporate Sustainability Report 2004–2005. Jamshedpur: Tata Iron and Steel Company Limited.

———. 2006. Indian Minerals Yearbook 2005. Nagpur: Indian Bureau of Mines. CSE. 2008. ‘Rich Lands, Poor People: Is Sustainable Mining Possible?’, The State

of India’s Environment: The 6th Citizen Report. New Delhi: Centre for Science and Environment.

Das, P. 2005. ‘Industrialization will Harm Orissa’s Ecology Greatly’, The Hindu Businessline, Chennai, 7 June, 38(4): 627–44. Available online at http://www.thehindubusinessline.in/2005/06/07/stories/2005060702321700.htm. Downloaded on 5 May 2009.

Dash, K.C. and C.S. Kishore. 2008. ‘New Mega Projects in Orissa: Protest by Potential Displaced Persons’, Social Change, 38(4): 627–44.

Davis, S. 2007. ‘Global Mining in Perspective’, Fourth World. Available online at http://sharondavis.co.za/content/view/63/3/. Downloaded on 30 June 2011.


Devotta, S. ‘Towards Sustaining Mining Industries in India: Challenges’. Nagpur: National Environmental Engineering Research Institute. Available online at http://www.teriin.org/events/docs/sukumar.pdf. Downloaded on 20 December 2008.

Frontline. 2007. ‘Dark side of Mining’, 24(9): 5–18.GoO. 2004. ‘Some Measures of Human Development: An Inter-district Analysis’,

in Orissa Human Development Report, Government of Orissa, Bhubaneswar. pp. 191–210.

GoO. 2008–09. Economic Survey Report of Orissa. Bhubaneswar: Directorate of Economics and Statistics, Government of Orissa.

Infochange India News. 2008. ‘Can Mining Ever be Sustainable, Asks CSE Report’. Available online at http://infochangeindia.org/200801306849/Environment/Books-Reports/Can-mining-ever-be-sustainable-asks-CSE-report.html. Downloaded on 26 April 2009.

Karyn, K.J. de Echave, and K. Traynor. 2002. Mining and Communities: Poverty amidst Wealth. Political Economy Research Institute, University of Massachusetts, Conference Paper Series No. 3.

Khatua, S. and W. Stanley. 2006. ‘Ecological Debt: A Case Study from Orissa, India’, in K.P. Athena (ed.), Ecological Debt: The Peoples of the South are the Creditors, pp. 125–68. Geneva: World Council of Churches.

Murthy, A.A. 2006. ‘Data on total area under mining collected, Status Paper on Mining Leases in Orissa’, Vasundhara, Bhubaneswar (based on information obtained under the RTI Act from Directorate of Mines, Orissa).

Panda, R. 2007. ‘Thirsty Mines, Disposed Communities’, in 6th Citizen Report, Rich Lands, Poor People: Is Sustainable Mining Possible? (2008). 350 pp. New Delhi: Centre for Science and Environment.

Ripley, E.A., R.E. Redman, and A.A. Crowder. 1996. Environmental Effects of Mining. Florida: St. Lucie Press.

Saxena, N.C., G. Singh, and R. Ghosh. 2002. Environmental Management in Mining Areas. Jodhpur: Scientifi c publishers.

Sethi, A. 2007, ‘Dark Side of Mining’, Frontline, 18 May, pp. 42–46.Sills, E., S.K. Pattanayak, S. Saha, J-C. Yang, P. Sahu, and A. Singha. ‘Mine Over

Matter? Health, Wealth and Forests in a Mining Area of Orissa’. Available online at http://www.freewebs.com/epgorissa/Mine%20Matter.pdf. Downloaded on 5 May 2009.

Srivastav, S., L. Pritchett, R. Damania, and K. Lvovsky. 2006. Environment and Social Challenges of Mineral-based Growth in Orissa: Building Partnership for Sustainable Development. Washington, D.C.: World Bank.

TERI. 2001. Overview of Mining and Mineral Industry in India. New Delhi: Tata Energy Research Institute.

Vasundhara. Available online at http://www.vasundharaorissa.org. Venkataraman, G. 1992. Environmental Impact of Iron Ore Mining in Goa through

Remote Sensing, Centre of Studies in Resources Engineering, Indian Institute of Engineering, Mumbai. Available online at http://www.csre.iitb.ac.in/gv/proj3/studyareap3htm. Downloaded on 23 November 2006.

PART V INCREASING URBANISATION

AND WATER AND HEALTH

334 Mohamed Mujithaba Mohamed Najim et al.

15

Wastewater in Sri LankaImplications on Human Health

MOHAMED MUJITHABA MOHAMED NAJIM AND INDIKA HARSHANI RAJAPAKSHE

INTRODUCTION

TRADITIONALLY IN SRI LANKAN villages domestic wastewater, especially grey-water generated from kitchens and bathrooms of a household, fl ows along open unlined wastewater drains and is collected in a garden pool known as kohila wala or vegetation pool. This pool is a kind of traditionally constructed wetland. Main vegetation type cultivated in the wetland is kohila (Lasia spinosa) which is used as a leafy and stem vegetable. Medicinal and other important plants are also grown along the drains that utilise the wastewater and its nutrients. This system of grey-water disposal and utilisation was always kept separate from the black-water disposal system as the latter is disposed to individual cesspits located in home gardens. In the traditional sys-tem, natural capacity to treat wastewater without any harmful effects to groundwater was possible due to low population density and land availability. With the population expansion in urban centres, the land value increased and land area available for the traditional wastewater treatment process shrank.

Sri Lanka has experienced a rapid growth of population in some areas, putting pressure on its land and water resources. Sri Lankan population in 2001 was 18.8 million and it was estimated at 19.37 million in 2005 (ADB 2006). Sri Lankan population can be classifi ed mainly into three categories; urban (including peri-urban), rural and estate (mainly labour force employed in the tea and rubber estates). Sector-wise population variation, according to the Census of


Population and Housing in 2001, shows 14.6 per cent, 80.0 per cent and 5.4 per cent respectively in urban, rural and estate areas respec-tively (DCS 2001). Out of the urban population in 2001, 14 per cent live in slums (World Bank 2005) and the slum population in greater Colombo area is 43 per cent (ADB 2006).The urban population in 2005 increased to 21 per cent (World Bank 2005) or 4.07 million. The estimated average growth of capital cities or urban agglomerations during 2005 to 2015 is 13 per cent. Increase in population has cre-ated many issues related to wastewater disposal such as deterioration of water quality and health.

Urbanisation is the driving force for modernisation, economic growth and development. Water supply and waste disposal systems are unable to keep pace with development under resource-poor environ-ments, leading to disposal of wastewater including grey-water from kitchens and/or bathrooms and black-water from toilets. The World Health Organisation (WHO) in its World Health Report of 2002 (WHO 2002) stated that unsafe water, sanitation and hygiene were one of the most important risk factors among developing countries. Most Southeast Asian countries fall into this group.

Urbanisation limited the land needed for traditional wastewater disposal mechanism that was being practised in the country. The grey-water generated is disposed mostly into a drain that is used primarily as a storm water drain, an irrigation canal or a natural water way, such as a rivulet or a streamlet. Black-water and other toilet wastes have contaminated natural, surface and groundwater sources such as streams, wells, springs, and so on due to poor sanitation, including inappropriate faecal matter disposal, inappropriate toilets and toilet pits and their improper installation and maintenance. On the other hand, Sri Lanka is blessed with high rainfall and perennial watercourses and it is unavoidable that cities are built close to water sources. This has resulted in intensifi cation of the water pollution problem.

Water pollution due to domestic and municipal discharges has affected potable sources of water posing serious health hazards. In Sri Lanka, diseases resulting from poor sanitation and hygiene rank among the leading causes of hospitalisation and ill health (Shanmugarajah 2002). Poorly managed wastewater in urban and peri-urban areas has created lots of health problems for the downstream community as well as the city dwellers.

Wastewater in Sri Lanka 337

This chapter is based on two case studies, one from Kurunegala district and the other from Pussella Oya catchment. One of the major health concerns in Kurunegala city itself is the high incidence of fi lariasis (Rajapakshe et al. 2007). On the other hand, Pussella Oya catchment is the source area for Hepatitis A and an outbreak was recorded in Gampola in May 2007. In fact, faecal pollution has contaminated water sources in Pussella Oya and many other catch-ments. Besides, expanding cities have increased the concern on effects, principally on human health, livelihoods and the environment. This problem is no longer simply an issue for environmentalists to deal with but requires other experts’ attention.

PROBLEMS OF WASTEWATER GENERATION IN SRI LANKA

The average water consumption in Sri Lanka is 120 l/capita/day, according to National Water Supply and Drainage Board (NWSDB). Wastewater return fl ow from water consumption is 70 per cent, which is an internationally accepted fi gure for wastewater genera-tion. Estimated annual wastewater generation in the country is about 400 million cubic metres. Out of this, 25 per cent is considered as black-water and the remaining as grey-water. The wastewater genera-tion can vary in volume according to geographical location, climate, people’s behaviour, level of industrialisation, urban population served with piped water, and so on. Most of the grey-water and a part of the black-water generated, are diverted to the sea or surface water bodies without any treatment.

Generally, urban wastewater generation is 20–40 per cent from the total wastewater generation in Sri Lanka. Urban wastewater is a combination of some or all of domestic effl uents consisting of black-water (excreta, urine and associated sludge), yellow-water (only urine), grey-water (kitchen and bathroom wastewater), water from commer-cial establishments and institutions (hospitals, industries, and so on.), storm-water and other urban runoff (Van der Hoek 2004). Levels of industrialisation are low in most of the cities in Sri Lanka. Therefore, the main risk in all cases appears to be from hospitals, service stations and slaughter houses which discharge untreated or partially treated wastewater. Most hospitals have treatment plants, but they function


poorly after an initial period of good operation. Most of the industries in the country have wastewater treatment plants, specially the ones in industrial parks or zones. Untreated or partially treated wastewater is disposed off into drains affecting downstream communities.

Massive volumes of urban wastewater generation weaken the natural wastewater treatment capability and necessitate conventional wastewater treatment. However, centralised conventional wastewater treatment facilities are limited to very few areas in Sri Lanka and the only major city that has a system is Colombo Municipality. Less than 25 per cent of wastewater in the Colombo Municipal Council area is treated through the system (ADB 2006).

DISPOSAL SYSTEMS IN SRI LANKA

There are many kinds of onsite excreta disposal systems used in latrines, such as cesspits or soakage pits, septic tanks, biofi lters, soakage trenches, sewage systems, dry composting pits, and so on. The trad-itional on-site excreta disposal mechanism in Sri Lanka includes soakage pits and the common excreta disposal mechanism involves use of septic tanks. It is reported that 80 per cent of the urban and suburban population in Sri Lanka use septic tanks for the disposal of faecal waste. The septic tank effl uents need further treatment before they are discharged safely. Therefore, septic tank and associated effl u-ent disposal systems need to be designed and implemented properly, in order to prevent failures, public health hazard and environmental pollution.

Sri Lanka Standard Institution (SLSI) has established guidelines (SLS 745–2003) for the design and construction of septic tanks and associated effl uent disposal systems. These guidelines propose primary, secondary and tertiary systems to treat the effl uents before discard-ing them safely, depending on the sink and source. The guidelines for primary treatment cover the design, construction, testing and maintenance of septic tanks for the disposal of domestic wastewater including black-water, grey-water and all waste systems. It also recommends guidelines for the selection, design, construction and maintenance of systems for the on-site disposal of effl uents from septic tanks as secondary and tertiary treatments. Based on a combination


of technical and fi nancial considerations and preferred option of disposal, that is reuse, disposal on ground, drain, and so on, different confi gurations are proposed for the disposal of septic tank effl uent for Sri Lankan conditions (Table 15.1).The proposed effl uent disposal combinations are not implemented in most of the cases as there is no methodology for implementation or to monitor the implementation of the proposed standards.

Table 15.1: Proposed Confi gurations for the Disposal of Septic Tank Effl uents for Sri Lankan Conditions

Preferred Option of Disposal Alternative Options

Disposal on ground Septic Tank (ST) → Soakage Pit → GroundST → Seepage bed → GroundST → Seepage trench → Ground

Disposal into surface drains and/or ground

ST → Biofi lter → Surface drainST → Constructed wetland (unlined) → Surface drain and/or GroundST → Constructed wetland (lined) → Surface drain

Disposal jnto surface water and/or re-use

ST → Constructed wetland (lined) → Constructed wetland (lined) → surface water/reuseST→ Constructed wetland (lined) → Percolation bed → Reuse and/or surface waterST → Biofi lter → Constructed wetland (lined) → Reuse and/or surface waterST → Biofi lter → Percolation bed → Reuse and/or surface water

Source: SLSI (2003).

Primary selection criteria in an excreta disposal system for a particular site are the type and porosity of the soil. The depth to seasonally fl uctuating water table and distance between water wells and septic tanks are also of concern. The minimum required distance (Table 15.2) varies depending on soil type (Werellagama et al. 2003).

According to the SLS 745, the most common single cause of failure of septic tank systems has been the indiscriminate use of soakage pits for the disposal of septic tank effl uents into the ground (SLSI 2003). Such failures are mainly attributed to poor attention paid on local soil conditions, groundwater table and urban congestion. Lack of


Table 15.2: Recommended Minimum Distances Between a Dug Well and Source of Faecal Contamination

Contamination Source Recommended Distance (m)

Building sewer 15 Septic tank 15 Disposal fi eld 30 Seepage pit 30 Cess pool 45

Source: Werellagama et al. (2003).

awareness of implementers and regulators of appropriate alternative cost-effective means of effl uent disposal has also contributed to the failures.

PROBLEMS RELATED WITH IMPROPER DISPOSAL OF WASTEWATER

Two locations were studied to identify major pollution contributors and the impacts of improper wastewater disposal mechanisms in Sri Lanka. The fi rst case study was conducted in Pussella Oya catch-ment, reaching all the three communities, estate, rural and urban, living in the catchment. The second case study was conducted in four selected Public Health Inspection (PHI) areas in Kurunegala district (including the city Kurunegala) to identify the variation in water related diseases and reasons for the identifi ed variations.

CASE STUDY 1: PUSSELLA OYA CATCHMENT

One of the reported impacts of poor sanitation in Sri Lanka was the outbreak of Hepatitis A in Gampola in 2007. Pussella Oya catch-ment (Map 15.1), a small tributary of the Mahaweli River, the largest river in Sri Lanka that covers one-third of the country, was identifi ed by the Ministry of Healthcare and Nutrition as one of the sources responsible for the outbreak of the disease due to water intake avail-able in the stream. Therefore, a case study was conducted in Pussella Oya catchment to identify the wastewater disposal mechanism and its impact on the society. Three different communities were selected

Wastewater in Sri Lanka 341M

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Figure 15.1: Surface Water Quality Variation among Different Communities in Terms of Infl ow and Outfl ow Water

to represent the three main community types as Rothschild Estate, Pussellawa Town and Black Forest Colony which represent the estate (tea plantations), peri-urban town and village (rural) communities, respectively (Map 15.1).

Deterioration of Surface Water

The average surface water quality variation among the three differ-ent communities in terms of infl ow and outfl ow water is shown in Figure 15.1. This difference indicates the contribution of the area to pollution. The outfl ow water quality (Total Coliform–5849 CFU/100ml and E. Coli –2272 CFU/100ml) is signifi cantly poor


when compared with infl ow water quality (Total Coliform–1328 CFU/100ml and E. Coli–379 CFU/100ml) in Pussellawa Town and in Rothschild Estate (Infl ow water quality: Total Coliform–2233 CFU/100ml and E. Coli–861 CFU/100ml. Outfl ow water quality: Total Coliform– 4731 CFU/100ml and E. Coli–1728 CFU/100ml). The highest pollution level of the outfl ow water was found from the Pussellawa Town area followed by the Rothschild Estate.

Pussellawa town is a densely populated peri-urban town commu-nity. Land area is limited to construct individual wastewater treatments and there is no common or centralised wastewater treatment system. However, toilet pits available in Pussellawa town are totally lined (due to shallow water table) with single compartment. These storages overfl owed or opened, after a temporary storing period, into the drain canals. The wastewater disposal from the town has led to signifi cant increase in the pollutant level (P < 0.01 for both total Coliform and E. coli) at outfl ow from town when compared with infl ow water qual-ity into the town (Figure 15.1). Additionally, high population density produces and directly disposes massive pollutant loads from a small area where there is no suffi cient space and time for natural treatment to take place. The main reason for this type of environmental disaster is unorganized urbanisation including inappropriate town/city plan-ning and inappropriate living conditions and livelihood.

Rothschild Estate contributes to surface water pollution with the existing wastewater disposal mechanisms. The estate community (100 per cent) disposes their grey-water from kitchen and wastewa-ter generated from bathing and washing clothes directly into nearby drainage system. Grey-water also contains faecal pollutants as a result of communities washing even clothes that are smeared with childrens’ stools. Among the studied population, 21 per cent of the population includes children less than 5 years. All the toilets in the estate dispose the faecal matter to unlined cesspits. Unavailability of toilets in public places as school (where the most of estate children are present during the school hours) and working fi eld (no toilet facilities available in tea estates) have led to open defecation. Black Forest Colony residents, basically villagers, have individual toilets per family with septic tanks or cesspits. Therefore, surface water pollution is comparatively less among village communities of Black Forest Colony.


Deterioration of Groundwater

The average groundwater quality variation among the three different communities is shown in Figure 15.2. The groundwater pollution in the Black Forest community is found to be comparatively higher (Total Coliform–1412 CFU/100ml and E. Coli–441 CFU/100ml) than the other two communities (Pussellawa town: Total Coliform–1068 CFU/100ml and E. Coli–287 CFU/100ml. Rothschild Estate: Total Coliform–737 CFU/100ml and E. Coli–200 CFU/100ml). Possible reasons for poor quality infl ow could be recharge of contaminants into the groundwater storage and availability of unsuitable latrine pits in the area. Groundwater existence is limited in Black Forest area that is available only in the valley closer to the stream. People reside in the valley, live very close to the stream and their toilet pits are also located in the same area. These toilet pits contribute much to contaminate the limited groundwater source available. On the other hand, the groundwater withdrawn from wells is water that is recharged by the stream.

The second highest groundwater pollution is found from Pussellawa Town area (Figure 15.2). Unlined cesspits and drainage canals cannot be used in this area due to seepage from shallow groundwater (a few cm from the land surface). Therefore, the toilet pits are completely lined with a single compartment and the city drainage canals are also totally lined within the city limits. Leakage through these linings might be the cause of existing pollution in the groundwater within the city limit. On the other hand, potential for groundwater contamination through leakages of the cesspits/drainage canals is minimal due to the negative hydraulic gradient often exist towards groundwater.

CASE STUDY 2: SELECTED PHI AREAS FROM KURUNEGALA DISTRICT

This case study was carried out in four PHI areas in Kurunegala district, namely Alawwa, Kudagalgamuwa, Kurunegala and Narammala (Map 15.2) to study the risks from water-related diseases in the area.


Figure 15.2: Groundwater Contamination in Black Forest Colony, Pussellawa Town and Rothschild Estate Communities

Deterioration of Health

Most prevalent water related diseases in Alawwa, Kudagalgamuwa, Kurunegala and Narammala PHI areas (Figure 15.3) were assessed using the government health statistics. Some of the cases were not reported at the provincial Ministry of Healthcare as they were mild infections and treatment was sought in private hospitals.

Kurunegala municipal council area is identifi ed as one of the high risk areas for dengue fever (DF) and dengue hemorrhagic fever (DHF) infections. This high incident could be due to improper solid waste disposal and/or availability of breeding sites in the densely populated city and peri-urban areas.


Map 15.2: Alawwa, Kudagalgamuwa, Kurunegala and Narammala PHI areas

The water related disease that is most prevalent after dengue is dysentery. Alawwa is the area that recorded maximum dysentery cases followed by Narammala and Kurunegala. Most of the Alawwa (62 per cent) and Narammala (51 per cent) residents use wells for potable water supply. A very small number of housing units are supplied with


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water by the authorities. Water wells that supply potable water could be contaminated due to poor sanitary facilities and their management. Most of the Kurunegala city is covered by the NWSDB water supply where 90 per cent of the population and 100 per cent of the area is covered ( Jayakody et al. 2006). Kudagalgamuwa, a rural area without a dense population, recorded least number of infected patients. This could be due to least opportunity of water sources contamination (suffi cient spacing between sanitation installations and water wells), lower groundwater table, and so on.

Alawwa recorded the highest incidence of hepatitis and dysentery from the study areas. This is refl ected by the poor sanitation cover-age in the area. About 10.2 per cent of the houses in Alawwa do not have toilets and 34.3 per cent do not have suffi cient sanitation facili-ties. Only 55.5 per cent of the houses have water sealed toilets. The highest number of leptospirosis and malaria cases were also reported from Alawwa area. The highest number of dengue and typhoid cases were recorded from Kurunegala PHI area. Kudagalgamuwa, an area which is not densely populated, recorded the least number of hepati-tis, dysentery and typhoid cases. This is an indication that the water sources used in this area are less prone to faecal pollution.

OTHER WATER POLLUTION RECORDS IN SRI LANKA

Deterioration of Groundwater

In highly populated urban and rural areas, groundwater pollution is reported due to poor location as well as inappropriate designs, con-structions and maintenance of septic tank systems. Larry and Robert (1985) have reported that areas with more than 40 septic tanks per square mile can be considered to have potential contamination prob-lems. In these densely populated centres, toilet pits or septic tanks are made very close to each other and even very close to wells due to limitation of land. Other than that storm-water drainage canals in these cities, mostly unlined and collecting the domestic and munici-pal wastewater, sewage through overfl owing of toilet pits or direct discharge of toilet wastes act as a very good source of pollution of the adjacent wells with recharge.


The population density in wet zone is about 957 persons/ sq. km whereas in the dry zone it is as low as 163 (Werellagama et al. 2003). But the population centres in the eastern part of the country are very high, for example, Sainthamaruthu District Secretariat division has 2,725 persons/sq. km). Nawas (2006) reported that 367 sq. m land area is available per person in Sainthamaruthu, 66 per cent families have only a dwelling area of 6.6–19.0 sq. m, 12 per cent families have only 6.6 sq. m or less, while majority (48.5 per cent) of the families possesses between 6.6–17.7 sq. m of land compared to the national fi gure of 3,453 sq. m. Meanwhile, the actual land area per person in Sainthamaruthu is 40 sq. m (Nawas 2006). Septic tank density in Sainthamaruthu is 5,432/sq. km (Nawas et al. 2006) and well density is 4,428/sq. km. Both wells and septic tanks are located in the same area (Nawas et al. 2005). Werellagama et al. (2003) agreed to the recommended distance of a minimum 15 m between a dug well and a septic tank system. However, the radial distances noted in Sainthamaruthu were less than 15 m between a well and a septic tank (Nawas 2006).The highly permeable sandy regosol soil will simply allow wastewaters to leach back to groundwater system.

The case study of Pussella Oya catchment shows groundwater pollution when cesspit systems are installed closer to wells similar to the fi ndings by other researchers such as Werellagama et al. (2003) and Nawas et al. (2005 and 2006).

Deterioration of Health due to Water-related Infectious Diseases

According to Rajapakshe et al. (2007) in areas adjacent to Wilgoda Anicut and surrounding canals in Kurunegala municipality, water-related vector borne diseases like Dengue and Filariasis were reported due to polluted water or improper management of water. This area is recorded as endemic for fi larial disease. Both DF and DHF continue to be major public health problems in Sri Lanka. The worst ever epidemic of DF and DHF was recorded in 2004 in which there were 15,467 suspected cases and 88 deaths.

Sri Lanka faced a Chikungunya fever outbreak in 2006. The most affected areas for the outbreak were Puttalam (11,125), Kalmunai (4,092), Colombo (5,286), Jaffna (1,512), Mannar (9,255), Batticoloa


(3,141) and Trincomalee (1,910). Over 37,600 suspected cases were reported from the country by the end of 2006.

The most prominent water-based disease reported from Sri Lanka is Leptospirosis, a bacterial disease, which rapidly spread to all the Deputy Provincial Director of Health Service (DPDHS) division in Sri Lanka (MHN 2007). It was an endemic disease in many parts of Sri Lanka. In 2006, 1,192 confi rmed cases were reported to the epidemiology unit (MHN 2007). Actual incidence of Leptospirosis is likely to be more than this as many patients with mild form of the disease did not seek treatment at all or were treated by private practitioners.

Most of the Leptospirosis cases were reported in Gampaha district in September 2005 and September 2006.The disease occurrence had been high during March–June and in the latter part of the year. About 84 per cent cases in the country and over 90 per cent in Gampaha have been men. The evidence shows the vulnerability of men in the productive age groups (MHN 2007). Paddy cultivation is common in most of the endemic areas and the peak incidence is seen during the paddy harvesting seasons due to an increase in rodent population in and around paddy fi elds. Paddy fi elds (46 per cent) and marshy muddy lands (35 per cent) have been identifi ed as the commonest probable source of infection in Gampaha (MHN 2007). Wastewater discharge will enhance the wetness or muddiness of paddy fi elds creat-ing a better environment for spread of disease .

Case Study 2 from four PHI areas from Kurunegala district shows the spread of water-related diseases. Major reasons behind the disease outbreaks are water pollution, mainly contamination with faecal mat-ter and improper water/wastewater management.

Deterioration of Irrigation Water

Tolerance limits are available for industrial effl uents discharged into inland water ways and on land for irrigation purpose in National Environmental (Protection & Quality) Regulation No.1 of 1990. Irrigation water quality guidelines are being developed. Kurunegala city wastewater exceeds the tolerance limits for discharging water to inland water bodies (IEE 2005), but for agricultural use, current


discharge quality is well within the range. Microbial water quality in many such drains has exceeded the tolerance limits or allowed limits proposed by the Central Environmental Authority (CEA). Use of polluted water, specially polluted with faecal matter, causes concerns for irrigators and consumers.

OTHER WATER-RELATED PROBLEMS

High concentrations of suspended solids in waters due to discharge of partially treated wastewater or illegal raw sewage discharges could impede switching from chlorination to less toxic and less hazardous disinfection methods such as ultraviolet light (Katonak and Rose 2003), which is very expensive for developing nations like Sri Lanka. Availability of organic pollutants in water will also lead to generation of toxic by-products that are carcinogenic if treated with chlorine. Water fl ow from the study areas presented in Case Study 1 is used for community water supply projects as well as intake for a water supply scheme of NWSDB. Faecal contamination of these sources as reported in the case study might cause many bad impacts on the water supply, purifi cation and the consumers.

Nutrient enrichment in water bodies by domestic wastewater, municipal wastewater, sewage discharges and other inorganic and organic pollutants from industries will lead to eutrophication where toxic algal blooms also grow. Toxic algae in water bodies damages aquatic mammals and birds and affect even humans who may ingest via contaminated aquatic food or inhale through contaminated sprays. It is reported that more than 60,000 human infections occur each year in the US alone due to ingestion of contaminated aquatic food or inhalation of contaminated sprays. In Sri Lanka, however, the number of people affected is not known. Eutrophication in freshwaters is becoming a serious problem in surface water bodies of Sri Lanka in Kotmale (Piyasiri 1995), Kandy lake (Silva 2003), Beira Lake, Kotmale reservoir (UNEP 2001), and so on. Suspended sediment materials reduce light penetration into deep layers of the water body. Moreover, water pollution creates an aesthetically appalling environ-ment emanating bad odour (Rajapakshe et al. 2007).


Effect of Rainfall on Disease Spreading due to Wastewater Pollution

Water-related diseases have direct relationship with the rainfall pat-tern. High incidences of water borne diseases are recorded in the initial part of the rainy season. For example, Hepatitis A outbreak in Gampola in 2007 happened during April–June, the initial part of the South–West monsoon, the main rainy season in the area. Most of the water-related diseases are prominent during the initial part of the South–West monsoon and the main reason is initial rains carrying high pollutant loads with the surface runoff. Studies in Sierra Leone (Wright 1986), Gambia (Barrel and Rowland 1979) and Nigeria (Blum et al. 1987) have all shown the highest faecal coliform counts in surface water sources after the start of the rainy season. The run-off due to high intensity rainfall from faecal polluted soil is one of the major reasons for the high faecal coliforms in surface water bodies that are responsible for water-borne diseases.

Total number and variety of disease incidents recorded at Alawwa, Kudagalgamuwa, Kurunegala and Narammala PHI areas are shown in Figures 15.4 and 15.5, respectively. The diseases are more concen-trated in the periods from May to August (South–West monsoon) and November to January (North–East monsoon). The fi ndings show that the most disease incidents are concentrated within the period just after the peak rainy seasons and during the inter-monsoonal seasons. Dengue appears the highest number of times from May to August (South–West monsoon) and from November to January (North–East monsoon). North–East monsoon reported sharp increases in DH and DHF cases in all the PHI areas studied that could be attributed to the heavy rainfall received throughout the North–East monsoon.

Dysentery is recorded mostly during May to August (South–West monsoon) and October to November (second inter-monsoon). The lowest incidents recorded are from December to April (North–East monsoon and the fi rst inter-monsoon) and the month of September. Leptospirosis is prominent in the months of February, harvesting period of Maha season and October (just after harvesting period of the Yala season). Typhoid shows the lowest occurrence from February to April (fi rst inter-monsoon). Other than the above differences,


Leptospirosis, Typhoid and Hepatitis do not show any signifi cant patterns in the distribution.

Alawwa PHI area has recorded the highest number of Hepatitis cases during the rainy seasons. The main source of water supply to Alawwa is the Maha Oya and the water is supplied by treating with chlorine disinfection alone. Alawwa PHI area has 172 houses without any toilets and due to the open defecation the water source could be infected with faecal pollutants. In Narammala, water supply source is groundwater abstracted by tube wells. During rainy season the groundwater table increases beyond the toilet pits promoting the transmission of bacteria to the water wells. Groundwater contamina-tion due to high density of population has been discussed by Nawas et al. (2005). Majority of the people live in Narammala PHI area use shallow water wells which could be contaminated with the faecal pol-lutants very easily. Water table rises beyond the toilet pit levels during the rainy season leading to groundwater contamination.

Figure 15.4: Total Number of Disease Incidents in Alawwa, Kudagalgamuwa, Kurunegala and Narammala Areas

354 Mohamed Mujithaba Mohamed Najim et al.Fi

gure

15.

5:

Typ

es o

f Dis

ease

s in

Ala

ww

a, K

udag

alga

muw

a, K

urun

egal

a, a

nd N

aram

mal

a A

reas


INSTITUTIONAL AND POLICY IMPLICATIONS IN WASTEWATER MANAGEMENT

The NWSDB, whose mission is to ‘save the nation by providing sustainable water and sanitation solution ensuring total user satisfac-tion’, is responsible for water supply and is in charge of the sewerage systems in Colombo, suburbs and other cities. Only a part of Colombo city has a sewerage system other than very small localised systems in the country. The sewerage network is limited to a small area serving approximately 25 per cent of Greater Colombo, and a large section of it is old and not operational. Built between 1906 and 1920, some parts of the system need urgent repair.

The sewerage system in Colombo is traditionally operated and maintained by the Colombo Municipal Council (CMC). Although NWSDB is the owner of the sewerage system, Operation and Main-tenance (O&M) has been undertaken primarily by CMC with no contractual agreement between NWSDB and CMC that specifi es performance standards and penalties for non-performance. There are no clear institutional arrangements for maintaining and operating the system. With no sewerage tariff being charged to water users connected to the system, CMC relies heavily on property taxes to help pay for O&M of the system.

The NWSDB initiated projects with foreign funding to install sewerage systems in Kandy and Kurunegala cities but these projects are yet to start operation due to diffi culties such as allocation of land, opposition by the stakeholders, lack of support from other organisa-tions, and so on. This delay in centralised wastewater systems is mainly due to the bad experience people have from the already installed systems in Colombo and in hospitals which are not functioning due to poor O&M, because of fi nancial shortage.

Other than the NWSDB, the wastewater management is consid-ered as one of the responsibilities of municipalities, urban councils or village councils known as Pradeshiya Sabha. In order to support these institutions, Sri Lanka Standard Institution (SLSI) has established guidelines (SLS 745–2003) for the design and construction of septic tanks and associated effl uent disposal systems. In addition, the estab-lishments of the CEA by an act known as the National Environmental


Act (Act No. 47 of 1980) and related amendments have given the legal framework needed in water pollution control and mitigation. The act has introduced National Environmental (Protection and Quality) regulations. According to the act and the regulations, the polluters have to obtain an Environmental Protection License (EPL) and need to make sure the effl uents discharged meet predetermined quality standards.

The major polluters from Case Study 1 are the low income estate workers who reside within the tea or rubber estates. SLS 745–2003 is not implemented in the estate sector and the unavailability of proper sanitation facilities increases the pollution risk of the streams which are acting as the sink. Due to unavailability of safe water supply, the down-stream low income communities utilise the contaminated fl ows for their domestic use. In Case Study 2, there are many polluters, namely low income communities, ignorant households, small industries and some service providers. The service providers and the small industries need to obtain EPL and the compliance is somewhat ensured through the local authority and environmental offi cers. Unfortunately, SLS 745–2003 is not implemented at all due to which the faecal pollution is a concern in some parts of the urban areas.

Even though the standards and regulations mentioned above exist, the major problem is the lapses in the implementation. The construction of septic tanks or related effl uent disposal mechanisms is not monitored and there is no means of regulating the construc-tion even though the prescribed standards are there. Once a polluter obtains EPL, there is hardly any monitoring to see whether the pol-luter is sticking to the discharge standards. In addition, the central wastewater system or the sewer system in Colombo is overloaded due to illegal connections given by interested parties due to wide-spread corruptions in the system.

The local government authorities responsible for issuing licenses for constructions or approving plans of buildings do not consider the land availability or zoning. This is mainly due to unavailability of a town plan or a town planning unit or experts on the subject. These authorities do not have a mechanism to implement standards on wastewater disposal such as SLS standard 745–2003.


The surface and groundwater resources come under different ministries, departments, authorities and institutions. Due to the nature of the cross institutional interests, the responsibilities are not taken by one institution leading to deterioration of the water resources. As there is no water management act in the country, the responsibilities are not vested on a particular department or ministry. This has led to the water pollution issues remaining unattended, thereby worsening the health implications as highlighted through case studies in this chapter.

CONCLUSIONS Population growth and urbanisation generate massive quantities of wastewater, thereby weakening the natural wastewater treatment capa-bilities. Although the SLSI has established guidelines for the design and construction of septic tanks and associated effl uent disposal systems, faecal contamination in many areas is attributed to poor attention paid to local soil conditions, groundwater table, urban congestion and lack of awareness of implementers and regulators on appropriate alternative cost-effective means of effl uent disposal systems. Groundwater pollu-tion is proving to be a disaster with the use of unsuitable technologies for excreta disposal and poor construction and maintenance of excreta disposal mechanisms.

Non-implementation of the proposed standards is blamed on inef-fective bureaucracy, poor motivation of the fi eld staff and fi nancial constraints in the implementation process.

Urban and peri-urban town communities are the highest pollut-ers in Sri Lanka. The main reason for this condition is unorganised urbanisation, including inappropriate town or city planning and inappropriate living conditions and livelihood. Urban and peri-urban town communities are highly vulnerable to water-related vector-borne diseases like DF due to poor solid waste and wastewater management practices. Water-borne diseases are negligible within the urban and peri-urban town communities which are supplied with safe drinking water. However, water-borne diseases are reported from areas with very high population density and where water from untreated natural


water sources such as shallow dug and tube wells are used. The prob-lems of urbanisation on wastewater management can be minimised by better country or town planning with adequate consideration to water supply and sanitation.

There are many institutional arrangements, Acts, regulations and standards in Sri Lanka but water pollution, both of surface and groundwater, and related health implications continue to increase due to non-implementation or monitoring of the pollution. It is necessary to coordinate among the responsible departments to deal with the issue of preventing or controlling water pollution and related problems. There are attempts by some projects funded by the public sector and also some initiatives by NGOs to change the situation. These projects attempt to improve water supply and sanitation through means of introducing better management practices such as upper watershed management, alternate technologies like ecological sanitation, water treatment facilities for service providers, and so on which have improved the situation at the grassroots level.

REFERENCES

ADB, 2006. Urbanization and Sustainability: Case Studies of Good Practice. Manila: Asian Development Bank.

Barrel, R.A.E. and M.G.M. Rowland. 1979. ‘The Relationship between Rainfall and Well Water Pollution in a West African (Gambian) Village’, Journal of Hygiene, 83(1): 143–50.

Blum, D., S.R.A. Huttly, J.I. Okoro, C. Akujobi, B.R. Kirwood, and R.G. Feacham. 1987. ‘The Bacteriological Quality of Traditional Water Sources in North–Eastern Imo State, Nigeria’, Epidemiology and Infection, 99(2): 429–37.

DCS. 2001. ‘Census of Population and Housing 2001: Kurunegala District – Final Results (CD)’. Sri Lanka: Department of Census and Statistics.

IEE. 2005. ‘Initial Environmental Examination Report in Respect of Greater Kurunegala Sewerage Project’, International Institute for Environment and Development, Ministry of Urban Development and Water Supply, Sri Lanka.

Jayakody, P., L. Raschid-Sally, S.A.K. Abayawardana, and M.M.M. Najim. 2006. ‘Urban growth and wastewater agriculture: A study from Sri Lanka’, Paper pre-sented at 32nd WEDC International Conference, Colombo, Sri Lanka.

Katonak, R. and J.B. Rose. 2003. Public Health Risks Associated with Wastewater Blending’. East Lansing: Michigan State University.

Larry, W.C. and C.K. Robert. 1985. Septic Tank System Effects on Groundwater Quality. Bosa Roca, USA: CRC Press.


MHN. 2007. ‘Sentinel Surveillance of Leptospirosis’, Weekly Epidemiologi-cal Report, 34(24):1–4. Epidemiological Unit, Ministry of Healthcare and Nutrition, Government of Sri Lanka, Colombo, Sri Lanka.

Nawas, M.F., M.I.M. Mowjood, and L.W. Galagedara. 2005. ‘Contamination of Shallow Dug Wells in Highly Populated Coastal Sand Aquifer: A Case Study in Sainthamaruthu, Sri Lanka’. Tropical Agricultural Research, 17(1): 114–24.

———. 2006. In print. Sustainable Use of Groundwater in Highly Populated Areas of the Coastal Belt of Sri Lanka’, in A.M.O. Mohamed (ed.), Arid Land Hydrogeology: In Search of a Solution to a Threatened Resource. The Netherlands: Taylor & Francis/Balkema, pp. 45–50.

Nawas, M.F. 2006. ‘Groundwater Pollution and Its Effects on Public Health in a Highly Populated Area: A Case Study in Sainthamaruthu in Kalmunai M.C.’ M.Phil. Thesis. Postgraduate Institute of Agriculture, University of Peradeniya.

Piyasiri, S. 1995. ‘Eutrophication and Algae Bloom Problem in Kotmale Reservoir, Sri Lanka’, in K.H. Timotius and Goltenboth (eds), Tropical Limnology, Vol II. Salatiga, Indonesia: Satya Wacana University Press.

Rajapakshe, I.H., I.P.P. Gunawardana, and M.M.M. Najim. 2007. ‘Problems Asso-ciated with Utilization and Management of Wastewater: A Case Study from Sri Lanka’, The Environ Monitor, 7(11): 4–13.

Shanmugarajah, C.K. 2002. ‘Health, Water and Sanitation’, in K.A.U.S Imbu-lana, P. Droogers, and I.W. Makin (eds), World Water Assessment Programme: Sri Lanka Case Study, pp. 97–105. Ruhuna Basins.

Silva, E.I.L. 2003. ‘Emergence of a Microcystis Bloom in an Urban Water Body, Kandy Lake, Sri Lanka’, Current Science, 85(6): 723–25.

SLSI. 2003. Draft Sri Lanka Standard: Code of Practice for the Design and Construc-tion of Septic Tanks and Associated Effl uent Disposal Systems. Colombo: Sri Lanka Standards Institution.

UNEP. 2001. Sri Lanka: State of the Environment 2001, United Nations Environment Programme, pp. 53–67. Available online at http://www.rrcap.unep.org/reports/soe/srilankasoe.cfm. Downloaded on 16 December 2008.

Van der Hoek, W. 2004. ‘A Framework for a Global Assessment of the Extent of Wastewater Irrigation: The Need for Common Wastewater Typology’, in C.A. Scott, N.I. Faruqui, and L. Raschid-Sally (eds). Waste Water Use in Irrigated Agriculture Confronting the Livelihood and Environmental Realities, CAB eBook, DOI 10.1079/9780851998237.0011, pp. 11–23. CABI

Werellagama, D.R.I.B., G. Herath, M. Hettiarachchi, and S. Basnayake, 2003. ‘Report on Recommendations and Suggestions on the Standard Distance between a Potential Faecal Pollution Source and a Drinking Well in Sri Lanka’, Water Quality Sri Lanka, NetWater, Sri Lanka.

WHO. 2002. ‘Reducing Risks, Promoting Healthy Life’, in World Health Report 2002. Geneva: WHO.

World Bank. 2005. World Development Indicators 2005. Washington, D.C.: World Bank

Wright, R.C. 1986. ‘The Seasonality of the Bacterial Quality of Drinking Water in Sierra Leone’, Journal of Hygiene, 96(1): 75–82.

16

Neglected FrontiersPeri-urban Water Use and Human Health in the

National Capital Region, India

VISHAL NARAIN

INTRODUCTION

IMPROVING HUMAN WELL-BEING, that is, the extent to which individuals have the ability to live the kind of lives that they value, and the opportunities to achieve that potential, is at the heart of develop-ment (UNEP 2007). Health and education are both seen to be the cornerstones of Human Capital (Dreze and Sen1989; Sen 1999). Health is viewed not only in terms of the absence of physical disease, but also in terms of its links with human well-being.

This chapter examines the health implications of water use and access in peri-urban settlements. The study focuses on peri-urban Delhi that includes not only the National Capital Region (NCR) of Delhi but also its surrounding cities of Gurgaon and Faridabad located in the state of Haryana. The chapter draws on a mix of secondary data for Delhi as well as research and fi eldwork carried out by the author in Gurgaon and Faridabad.

The term ‘peri-urban’ defi es any categorical defi nition. It is a rather loosely-used term denoting contradictory processes and environ-ments (Iaquinta and Drescher 2000). Broadly speaking, however, the word peri-urban could be used to denote a place, concept or a process (Narain and Nischal 2007). As a place, peri-urban refers to rural fringe areas surrounding cities; villages that are near the admin-istrative and geographical boundaries of the city. Brook et al. (2003) argue that peri-urban is better understood as a process; it represents a

Neglected Frontiers 361

transition between rural and urban and the fl ow of goods and services between villages and urban centres. As a concept, peri-urban could be understood to denote an interface across three systems, namely the agricultural system, the urban system and the natural resource system (Allen 2003). In this sense, we refer to peri-urban as an interface of rural and urban activities, processes and institutions.

THE CASE OF DELHI: AN EMERGING PERI-URBAN INTERFACE

India’s capital Delhi, an important and fast-growing city of South Asia, has a specifi c position in the Indian institutional system (Maria 2008). It is located in the NCR which has a status similar to the other states of the Indian federal system. The population of Delhi has risen steadily in recent decades (NCRPB 1999) from 1.7 million in 1951 to 4.1 million in 1971, 9.4 million in 1991 and 13.4 million in 1999. According to Census 2001, the population of the NCR of Delhi was 13.85 million people, to which can be added the more than 3 million people living on the extensions of Delhi’s urban agglomeration (UA) outside the NCR (Maria 2008). The NCR’s population is expected to grow to over 19.5 million by 2011 (NCRPB 1999) and by 2021, this fi gure should rise to somewhere between 22 and 23 million. With another 10 million people in different adjacent cities, this will be the world’s second largest UA after Tokyo (Maria 2008).

Currently only 50 per cent of the total area (1483 sq. km) is urban-ised. The UA of Delhi extends its limits out of the NCR, with regions like Gurgaon, New Okhla Industrial Development Area (NOIDA), Faridabad and Ghaziabad growing in the vicinity in the neighbouring states of Haryana and Uttar Pradesh. A large number of migrants from neighbouring states have made their home in Delhi in recent years; while some have settled in the heart of the city, a vast majority has been absorbed in the peripheral areas (Kundu 2008). This, along with a real estate boom, and the development of major transport corridors, has led to the emergence of a peri-urban interface PUI in almost all directions around Delhi.

362 Vishal Narain

A conspicuous PUI has emerged around Delhi particularly in Gurgaon and Faridabad districts of Haryana. Since the 1990s, in both these districts there has been a massive land acquisition process; land has been acquired by the State and private corporations for industrial, residential and recreational purposes, reducing space for agriculture and allied activities. Both these districts have emerged as major industrial and outsourcing hubs and have drawn in a large number of settlers in recent years.

The growth of these districts, however, has put tremendous pressure on their fragile infrastructure and natural resources. The lack of plan-ning to accommodate the new settlers has begun to show, particularly in Gurgaon. Even as residential areas with modern facilities are built, Gurgaon has been plagued by poor infrastructure, especially badly maintained roads, erratic power supply and a growing pressure on its water resources. According to the Central Ground Water Board (CGWB), 70 per cent of Gurgaon’s water needs are met through groundwater and the water table is dropping at the rate of about 1m every year. Offi cially, Gurgaon has been declared a ‘dark zone’ by the CGWB in terms of groundwater overexploitation. However, this has not stopped the government from its current pace of urbanisa-tion marked by huge residential complexes and malls. Groundwater is the only source of irrigation for large parts of the district. Where the groundwater is saline, this emerges as a major constraint to agriculture, except when this can be overcome through sewage based irrigation.

Faridabad faces a similar stress on its water resources. Isolated groundwater mounds and troughs in different parts of the district are known to have been created because of heavy pumping in the city area (GoI 2007). In general, the water table level has declined all over the district; this trend was particularly conspicuous during the 1980s, when the growth of the city started picking up. During June 1983 to 1993, a decline of water table level from 1 to 6m was observed in different parts of the district, being more pronounced in the southern blocks. Besides, drying of tube wells in the eastern parts of Faridabad and Ballabgarh blocks is also indicative of the stress on the ground-water resources.


WATER ACCESS IN PERI-URBAN SETTLEMENTS

Peri-urban settlements tend to be at the receiving end of urban growth and bear the brunt of development of urban residential and industrial areas. Pressures on water can come from many quarters; farmers’ access to water for irrigation may be adversely affected as groundwater is channelled towards other competing uses like industrial units, farmhouses and recreational activities. People’s access to water sources diminishes as the land on which they are located is acquired for urban and residential purposes. Factories located at the village peripheries may pollute local water sources. Besides, inhabitants of peri-urban settlements tend to be outside the ambit of the provision of organised sources of water supply.

Links with Land and Tenure

It is well established that access to organised sources of drinking water is shaped by land tenure status. This may leave a large part of the population in a city outside the ambit of any organised source of water supply, including drinking water. Thus this population has to depend on unorganised sources, even for drinking water, and tap groundwater supplies that are usually contaminated and unfi t for human consumption. Maria (2008) estimates that only around 43 per cent of Delhi’s population lives in settlements where the responsibility of the government-run Delhi Jal Board (DJB) to provide individual water supply is well defi ned and implemented.

The main determinant of access to water is the category of housing stock and land tenure. The different categories of housing stock exist-ing in Delhi are listed in Table 16.1. Table 16.2 gives the relationship between the category of housing stock, tenure, poverty and access to individual water supply connection.

The table shows that apart from the planned colonies and regu-larised but unauthorised colonies, it is only the urban villages that get water supply from DJB. This leaves the population residing in JJ clusters, resettlement colonies, non-regularised and unauthorised colonies, slum designated areas and rural villages outside DJB’s ambit. Many of these settlements are at the peripheries of the city, lacking access to organised sources of water supply.

364 Vishal Narain

Tab

le 1

6.1:

Cat

egor

ies

of H

ousi

ng S

tock

in D

elhi

Cat

egor

yD

escr

iptio

n

Squa

tter

sett

lem

ents

Jhu

ggi–

Jhop

ri (J

J)1 c

lust

ers o

r squ

atte

r set

tlem

ents

ille

gally

occ

upie

d on

pub

lic o

r priv

ate

land

. T

hey

belo

ng to

the

mos

t vul

nera

ble

type

of s

ettle

men

t in

term

s of l

ivel

ihoo

d.

Lega

lly n

otifi

ed sl

ums

Tho

ugh

the

term

‘slu

m’ i

s oft

en u

sed

as a

n eq

uiva

lent

of s

quat

ter s

ettle

men

ts, i

n D

elhi

this

adm

inist

rativ

e ca

tego

ry re

fers

to se

ttle

men

ts th

at h

ave

been

bro

ught

und

er th

e pu

rvie

w o

f the

Sl

um (I

mpr

ovem

ent a

nd C

lear

ance

) Act

of 1

956.

The

se se

ttle

men

ts h

ave

a le

gal s

tatu

s unl

ike

the

JJ c

lust

ers,

but a

re c

onsid

ered

unfi

t as

per

sani

tary

con

ditio

ns. S

ince

ver

y fe

w J

J cl

uste

rs h

ave

been

re

gula

rised

in re

cent

dec

ades

, mos

t set

tlem

ents

in th

is ca

tego

ry a

re th

ose

that

initi

ally

cam

e un

der

the

1956

Act

and

are

loca

ted

in th

e ol

d ci

ty a

nd it

s ext

ensio

ns.

Res

ettle

men

t col

onie

s M

ost o

f the

pub

lic in

terv

entio

ns d

irect

ed to

war

ds sq

uatt

er se

ttle

men

ts in

Del

hi h

ave

resu

lted

in

evic

tion

and

form

atio

n of

rese

ttle

men

t col

onie

s, us

ually

loca

ted

in th

e pe

riphe

ral a

reas

of t

he c

ity.

Una

utho

rised

col

onie

sIn

an

unau

thor

ised

colo

ny, l

and

is su

b-di

vide

d ill

egal

ly, u

sual

ly b

y ill

egal

dev

elop

ers,

and

sold

as

plo

ts. T

he su

b-di

visio

n is

illeg

al fo

r it v

iola

tes z

onal

and

/or s

ub-d

ivisi

onal

regu

latio

ns, o

r the

re

quire

d pe

rmiss

ion

from

land

sub-

divi

sion

has n

ot b

een

obta

ined

. Lan

d m

ay b

e pr

ivat

ely

owne

d,

unde

r not

ifi ca

tion

for e

xpro

pria

tion,

resu

lting

in a

gric

ultu

ral l

and

or c

omm

on la

nd o

f a v

illag

e ta

ken

over

for c

ity g

row

th. T

he a

rea

is no

t elig

ible

for e

xten

sion

of in

fras

truc

ture

serv

ices

.


Reg

ular

ised-

unau

thor

ised

colo

nies

T

his h

as b

een

cons

ider

ed b

y au

thor

ities

as e

arly

as 1

961

and

since

then

, sev

eral

wav

es o

f re

gula

risat

ions

hav

e fo

llow

ed. R

egul

arisa

tion

prov

ides

the

resid

ents

with

an

impr

oved

lega

l re

gim

e of

ow

ners

hip

and

impr

oved

infr

astr

uctu

re. H

owev

er, t

he u

nwill

ingn

ess o

f plo

t hol

ders

to

pay

the

regu

laris

atio

n ch

arge

s and

to fo

llow

the

regu

laris

atio

n pl

ans h

as le

d to

onl

y a

part

ial

impl

emen

tatio

n of

thes

e sc

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366 Vishal Narain

Tab

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.


ACCESS TO WATER FOR DIFFERENT CONSUMPTIVE PURPOSES

Wide Chasm between Core and Periphery

A vast proportion of the population that lives away from the heart of the city stays outside the ambit of formal sources of water supply. There is a huge difference in access to safe drinking water between the core and periphery areas, the latter positioned at a clear disadvan-tage. In general, peri-urban settlements tend to be marginalised when it comes to access to safe water and sanitation. Datta et al. (2001) noted that 87 per cent of the total water consumption in Delhi was for domestic purposes. The existing water supply distribution in the city, however, is highly uneven, with seasonal variations in different zones, colonies within zones, and even from fl oor to fl oor (Zerah 2000). Rohilla et al. (1999) reported that the Cantonment area (in central southwest Delhi) with low population density got 509–650 lpcd (litres per capita per day) of water, while some north-western and northern areas of Delhi with high population density received as little as 25–31 lpcd of water. Delhi’s villages, spread in over 50 per cent of the area, covering west, north-west and north Delhi, got less than 5 per cent of the water supply for the city.

The 1980s were declared the International Decade for Drink-ing Water Supply and Sanitation. In 1981, 95 per cent of urban households had safe drinking water facility in Delhi as opposed to the national fi gure of 75 per cent (Kundu 2008). The city recorded an improvement in the fi gure by just 1 per cent during that decade. Further, in 1991, 21 of the 33 towns in Delhi received less volume of drinking water than the rest of the city. Interestingly, most of these towns were located in the peripheral areas. Households in three of these towns—Rajokri, Patparganj and Nanangawal Dewat—received water supply well below the national average for urban areas. On the contrary, the New Delhi Municipal Corporation (NDMC) and the Delhi Metropolitan Council (DMC) areas and a few settlements located in the heart of the city had more than 97 per cent of their households covered by this facility (Kundu 2008).

368 Vishal Narain

The Census defi nition of safe drinking water is restricted to water sourced from taps, hand pumps and tube wells only. Groundwater in several parts of NCR has been found to be polluted, carrying toxic chemicals and other harmful particles. It would, therefore, be relevant to consider the data on the percentage of households with access to tap water instead of considering all sources of drinking water. By this benchmark, in 1981, only 68 per cent of the households in Delhi were covered by tap water while fi gures for the centrally located areas such as the NDMC and the Cantonment were above 85 per cent (Kundu 2008). On the contrary, most of the fringe towns had less than 30 per cent of their households with access to this facility. Shockingly, households in periphery towns like Babarpur, Jaffrabad and Nasirpur received water supply as low as 1.3 per cent, 1.5 per cent and 2.4 per cent, respectively (Kundu 2008).

Absence of Sanitation

The same discrepancy exists regarding access to sanitation. As per the 1981 Census, at the start of the International Drinking Water Supply and Sanitation Decade in 1981, the percentage of households with toilet facilities in the NCR of Delhi was 68 per cent, about 10 percentage points above the national fi gure (Kundu 2008). While the national fi gure went up during the 1980s, Delhi saw a fall in percent-age during this period. For Delhi, this fi gure came down from 81 per cent in 1988 to 71 per cent in 1993. Further, 25 out of the 33 towns had lower percentage of households with access to toilets compared to the average fi gure of NCR of Delhi in 1991 (Kundu 2008). It is important to note that most of these towns were on the periphery, such as Alipur, Bawana, Kotla, Mahipalpur, Pooth Khurd, Roshanpura, Sutanpur Majra and Tigri.

Water and Health

Lack of access to safe drinking water and sanitation is known to cause severe health problems. These can be grouped into the following categories:

1. Water-borne diseases such as Diarrhoea, Dysentery, Cholera and Typhoid caused by consumption of contaminated water


2. Water-washed diseases such as skin and eye infections caused by lack of personal hygiene due to water scarcity

3. Water-based or other water-related diseases such as Malaria, Bilharzia, Elephantiasis and River Blindness, related to exposure to unsafe water situations

As most of the diseases mentioned above are caused by poverty and social exclusion, residents of peri-urban settlements are particularly vulnerable to such diseases and also suffer from poor health. Indeed, the high incidence of water-borne diseases in peri-urban areas is the result of poor access to water and unsafe hygienic conditions. Several waterborne diseases such as Cholera, Diarrhoea, and Gastroenteritis are known to be a common cause of poor health and high morbidity in developing countries. The outbreak of water-borne diseases occurs annually in Delhi (Sharma 2006). Particularly, outbreaks of Cholera have been reported often (Sharma et al. 2003) and diarrhoeal diseases have also been widespread (Dasgupta 2004).

Sharma et al. (2007) note that Cholera is endemic in Delhi and its peripheral areas. Children below fi ve years constituted about 33 per cent of the cases in their study conducted between 2003 and 2005. Enhanced surveillance, however, brought down the cases from 48 per cent in 2003 to 37 per cent in 2005. In a similar study, Gupta et al. (2007) noted cholera to be fairly widespread in Delhi among children below three years. In their study, two-thirds of the cases were reported among children below the age of two. Very young children were equally vulnerable to the disease. The peak season for cholera in Delhi is from May through September.

In the absence of access to organised sources of drinking water supply, a large number of households in the peripheral areas depend upon hand pumps or tubewells that are not safe sources of water (Kundu 2008). Studies have shown the presence of faecal coliforms in a majority of samples collected for observation; microbial contami-nation of groundwater is known to be widespread and even deeper layers of groundwater may not be regarded as free from disease-causing micro-organisms (Sharma et al. 2003). This explains the incidence of epidemics and a variety of skin diseases in the peripheral towns, especially in the low income areas and slums.

370 Vishal Narain

Diminishing Access to Water for Peri-urban Residents

While peri-urban areas are already at a disadvantage in terms of access to safe drinking water and sanitation, this stress is further aggravated by trends in urbanisation processes that diminish the access of local residents to water sources of suffi cient quantity and quality. In a village called Sultanpur in peri-urban Gurgaon, where the author conducted a research study, the land on which the water supply tank was located was proposed to be acquired by Reliance Industries (a corporate giant) for a Special Economic Zone (Narain 2007). This tank, operated by the Public Health and Engineering Department (PHED), was the source of drinking water for most of the village. Once the land was acquired, villagers lost access to an important source of water supply. Besides, the acquisition of land in Sultanpur for the construction of a highway further inconvenienced the peri-urban residents as their approach route to the water source was obstructed. Since the local groundwater is saline, residents of Sultanpur get water from a hand-pump that is around 1.5 km away. The residents had to cross a railway track to reach the hand pump. With the construc-tion of the highway, their route was diverted and they had to walk a longer distance to get water. This added more drudgery to the already stressed life of the peri-urban residents. Human health is affected not only by consumption of contaminated water and reduced access to safe water, but also when simple chores like collecting water become more arduous and stressful.

Location of Water Treatment Plants

Very often water treatment plants supplying water to the city are located in peripheral villages. In village Basai, where the author con-ducted his research, when a water treatment plant emerged to supply water to Gurgaon city, it turned out to be a mixed blessing for the village population (Narain 2009). While it provided drinking water to the residents of Basai and even supplied water for irrigation to some farmers, the location of the plant eventually led to a rise in the local water table level, posing a threat to residential buildings in the region. (Leakages from the broken pipes fl ooded the ground and seeped into the water table, causing a rise in the water table). Constant water


leakages from the treatment plant resulted in mosquito breeding, causing an increase in vector-borne diseases. Villagers considered the plant a menace, as it had affected their lives in a very negative way.

Location of Factories at the Periphery

Both the fi rst and second Master Plans of Delhi have recognised the threat of health problems due to burgeoning industries that are both polluting and non-conforming in the peripheral regions. However, despite the threat the authorities have not invested in basic amenities. This growth has put tremendous pressure on the existing amenities in towns and villages in the hinterland, contributing to the process of what Kundu (2008: 70) calls ‘degenerated peripheralisation’.

Two factors contributing to the growth of UAs are the process of industrial decentralisation and the imposition of a stricter policy, reducing pollution in major cities in order to comply with global requirements. The failure of the state executive and legislature to effect changes in the urban environment, coupled with the increasing pressures of investment agencies, Multinational Companies (MNCs) and Transnational Companies (TNCs) has resulted in peripheral areas facing the brunt of relocation of polluting industries. The Supreme Court of India has often issued directives for the closure of hazard-ous polluting industries in the urban core areas and their relocation in periphery areas, preferably in the extended metropolitan zones or the peri-urban regions (Kumar 2001).

Many industries are located at the edge of the city because the waste that they produce rarely receives adequate treatment. Com-munity members often take advantage of the fact that in peri-urban areas the regulatory capacity of the government authorities is weak, particularly in areas outside the municipal boundaries (Parkinson and Tayler 2003).

The location of factories near the phirni (boundary) of Shahpur Khurd village in Faridabad led to noise and groundwater pollu-tion. The untreated waste from the factories found its way into the groundwater aquifers (Narain and Nischal 2007). These factories were relocated from Delhi and identifi ed as a ‘nuisance’ by peri-urban residents. Residents complained of hearing constant vibrations from the ground caused by factory operations. They wanted that these

372 Vishal Narain

factories be located far from their village, and particularly far away from their places of worship. The relocation of these factories at the village periphery contaminated village aquifers with pollutants, render-ing them unfi t for human consumption. The factories also discharged their wastes into local village ponds, reducing their attractiveness and usefulness as local water sources.

Use of Wastewater in Agriculture

It has been noted that wastewater has a high potential for reuse in agriculture (WII–IWMI 2006). It offers an opportunity for increasing food and environmental security while preventing direct pollution of rivers and surface water. This practice conserves a signifi cant propor-tion of the river basin waters and disposes off municipal wastewater in a low-cost, sanitary manner. Besides, wastewater production is continuous, making it a reliable and demand-based source available to farmers whenever they need it, unlike canal irrigation (IWMI 2003). It also allows farmers to grow crops that are more sensitive to water stress, such as vegetables. The nutrients present in wastewater are an added benefi t, saving farmers money (in terms of chemical fertilisers) and increasing crop yields. Though wastewater use in agriculture is an age-old practice, there is not enough systematic information on it, particularly on issues such as farmers’ needs and preferences and health and environmental risks (WII–IWMI 2006).

The use of wastewater for irrigation is a positive way to dispose off urban sewage water (Feenstra et al. 2000). This water contains lots of nutrients and can serve as an alternative water source in arid and semi-arid areas. Sewage-irrigated crops enable farmers to overcome constraints to farming posed by poor quality groundwater or the absence of an irrigation canal. This substantially widens the farmers’ cropping choices.

In peri-urban Delhi, wastewater is used for growing vegetables, foodgrain and horticulture crops and aquaculture (WII–IWMI 2006). Sewage irrigation was prevalent in one of the villages, namely Basai, studied in Gurgaon district by the author. The discharge of sewage from the city of Gurgaon became an important source of irrigation for cultivation of paddy that would otherwise have not been possible given the poor availability of groundwater and the absence of canal


irrigation in the district (Narain 2009). The benefi ts of sewage based agriculture were shared among peri-urban residents, depending on the location of their fi elds. The sewage water from Gurgaon city is auctioned by the Haryana Urban Development Authority (HUDA) among different villages and the winner distributes the water to farmers at a predetermined rate (approximately ` 900–1000 ($ 45) per hour).

The World Health Organization (WHO) advises treatment of wastewater before channelling it to fi elds to protect farmers and crop consumers. However, in Pakistan, India and other developing countries, farmers use this water without any treatment as treatment plants prove to be expensive. Besides, farmers prefer to use untreated water since its composition allows them to increase the fertility of the soil substantially. While this practice helps create livelihoods for a sig-nifi cant number of people from the vulnerable communities, mainly small and marginal farmers and the landless, its use is known to result in health risks to people. Wastewater contains a wide spectrum of pathogens, heavy metals and organic compounds that are hazardous to the environment and human health.

Prolonged contact with wastewater can expose farmers and their families to health risks such as parasitic worm infections and several viral and bacterial diseases. Consumers are also at risk eating vegetables irrigated with untreated wastewater; and wastewater canals can act as habitats for vectors, such as snails and mosquitoes. Another adverse impact of the use of urban wastewater in peri-urban agriculture is the deterioration in quality of stream water and groundwater as well as in soil quality.

Contamination of irrigated water by sewage and industrial effl u-ents is largely due to the presence of heavy metals beyond permissible limits under the Indian Prevention of Food Adulteration Act, 1954 (Marshall et al. 2003). Prolonged consumption of heavy metals in foodstuffs is known to lead to disruption of numerous biological and biochemical processes in the human body. While some elements such as Arsenic, Cadmium and Chromium act as carcinogens, others, such as Mercury and Lead, are associated with developmental abnormali-ties among children.

374 Vishal Narain

To check their heavy metal content, Singh and Kumar (2006) studied samples of vegetables like spinach and okra and samples of irrigated water and soil collected from fi ve peri-urban sites in Delhi. While the presence of heavy metals in the soil was below the maximum limit prescribed by WHO, the metal load was higher in the water and vegetable samples. The spinach and okra samples showed Zinc, Lead and Cadmium levels higher than the prescribed WHO limits. The level of Copper, however, was within safe limits. It was observed that metal contamination was higher in spinach than in okra.

Likewise, Kaur and Rani (2006) observed that Chromium concen-trations in the wastewater used for irrigation in Alipur and Shahdara blocks of peri-urban Delhi were far above the maximum permissible limit of one ppm (parts per million). Available Manganese concen-trations in the soil sampled at Kanjhawala, western Najafgarh and Alipur peri-urban regions in Delhi were also observed to be above maximum permissible limit of 10 ppm. A study by Rattan et al. (2005) focused on peri-urban agricultural lands under the Keshopur Effl uent Irrigation Scheme in Delhi where various cereals, millets, vegetables and fodder crops are grown. Their study found that sewage effl uents contained higher amounts of Phosphorus, Potassium, Sulphur, Zinc, Copper, Iron, Manganese and Nickel compared to groundwater. Risk assessment of metal contents in some vegetable crops grown in such contaminated soil indicated that these vegetables could be consumed safely by humans.

CHALLENGES FOR PUBLIC POLICY AND GOVERNANCE

From a public health perspective, there is an urgent need to address the challenges of wastewater use in agriculture. This is more so in view of its rising importance and the attendant health risks to farmers and consumers. Recent studies in several Asian and African cities have revealed that wastewater agriculture accounted for over 50 per cent of urban vegetable supply (IWMI 2003). Studies across 50 cities in Asia, Africa and Latin America show that wastewater irrigation is a common reality in three-fourths of the cities (IWMI 2006). Within South Asia, in Pakistan, for instance, wastewater irrigation provides a quarter of all vegetables produced (IWMI 2006). Wastewater farmers


typically earn 30–40 per cent more per year than farmers using con-ventional sources of water for irrigation (IWMI 2006). Wastewater is used often to grow rice and fi sh. In India and other countries, it is also used to grow fodder for livestock and thus contributes in the thriving small-scale enterprise of many villagers providing milk to city dwellers. Besides, wastewater is now commonly used for fl oriculture.

In the past, fragmented attempts have been made to address this problem, largely focussing on technical solutions such as wastewater treatment or regulatory measures, such as banning wastewater irriga-tion or restricting the types of crops to be irrigated (IWMI 2003). Both approaches have failed in low-income countries. The long-term goal of integrated wastewater management should be to move from the unregulated use of untreated wastewater to the regulated use of treated wastewater. Helping farmers to reduce crop contamination or improve water quality before application through on-site treatment is a possible medium-term goal. In addition, simple interventions like enforcing existing pollution control legislation to control contami-nants at source and to prevent the mixing of industrial and domestic wastewater can be very effective in reducing health risks.

Authorities could also reduce health risks to farmers and consumers easily if they provide the former in urban and peri-urban areas with safer water sources. In Cotonou, Benin, for example, the authori-ties recognised the contribution of urban agriculture to the city and allocated new land to urban farmers outside the city with unpolluted shallow groundwater, while in Accra, Ghana, the Ministry of Food and Agriculture has been exploring options for groundwater use in urban agricultural areas currently irrigated with water from city drains (IWMI 2003).

Further, when irrigation projects are centrally managed and laws are strongly enforced, it is possible to introduce restrictions to ensure that wastewater is not used to irrigate high-risk crops, such as leafy vegetables that are eaten raw. Researches in Mexico, Chile and Peru show that this is most likely to be successful when the crops allowed under restrictions are of similar profi tability and in high demand (IWMI 2003). If restrictions cannot be enforced, then public aware-ness campaigns might reduce consumer demand for crops that pose a health risk and thus indirectly infl uence farmers’ choice of crops.

376 Vishal Narain

Further, an important option for complementary risk reduction is washing and disinfecting vegetables at home and at the food outlets. From the treatment perspective, emphasis should be placed on options to treat chemically polluted wastewater before it enters the domestic wastewater stream used for irrigation.

Evidence of the growing recognition of the problem of the use of wastewater in agriculture can be seen in forums like the Hyderabad Declaration on Wastewater Use in Agriculture. The Hyderabad Declaration was the result of a workshop entitled ‘Wastewater Use in Irrigated Agriculture: Confronting the Livelihood and Environmen-tal Realities’, held during on 11–14 November 2002 in Hyderabad, India and sponsored by IWMI, based in Colombo, Sri Lanka and the International Development Research Centre (IDRC), based in Ottawa, Canada. The declaration emphasised the need to:

Safeguard and strengthen livelihoods and food security, mitigate health and environmental risks and conserve water resources by confronting the realities of wastewater use in agriculture through the adoption of appropriate policies and the commitment of fi nancial resources for policy implementation (CGIAR 2009).

The declaration also emphasised the need for greater research and institutional collaboration to address issues of wastewater use.

Case studies from around the world show that sanitation, agricul-tural, environmental and health guidelines are usually the responsi-bility of different agencies, and therefore either often overlap or are in confl ict. Besides, urban and peri-urban agriculture has no offi cial recognition in many countries. Multi-stakeholder platforms are vital to fi nd mutually satisfactory guidelines with a high potential for institutionalisation, cutting across the narrowly defi ned domains of rural development and urban planning.

Expanding Access to Safe Water and Sanitation

Improving synergies between local governments, Non-Government Organisations (NGOs), local civil society and the private sector can go a long way in supporting the positive aspects of rural–urban interac-tions while reducing their negative impact (Tacoli 2002). Worldwide, the balance of evidence on innovation in the PUI points towards the


potential of local level approaches, particularly in improving access to safe water and sanitation. In peri-urban areas that are in transition from rural to urban, and have inadequate institutional cover, mak-ing it diffi cult to bring them directly within the purview of rural and urban jurisdictions, Civil Society Organisations (CSOs) can lead the way. They have enormous potential to improve local environmental conditions, resolve confl icts in governance and scale up environmental management activities (Dahiya 2003). There are several local level initiatives that have addressed the current peri-urban challenges in South Asia (Dayaratne and Samarawikrama 2003, Ahmed and Sohail (2003), Halkatti et al. 2003, Dahiya 2003). These examples are worth replicating and need to be scaled up.

CONCLUSION

This chapter has examined the various ways in which urbanisation impacts access to water, both in terms of quantity and quality, for peri-urban residents. Drawing on the case of Delhi, it is observed that peri-urban residents are at a disadvantage since they often lack access to organised sources of safe water. Very often, peri-urban residents live in areas that lack legal tenurial status. This can be an important factor in increasing the incidence of water-borne diseases among them. Further, peri-urban residents can lose access to safe water in many other ways as processes of urbanization unfold. As urbanisation advances in the South Asian region, peri-urban challenges will need more urgent attention. Addressing these issues would require a mix of public policy interventions, such as those to address the problem of wastewater use in agriculture, as well as civil society initiatives to improve access to safe water and sanitation in peri-urban areas with poor institutional cover.

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Parkinson, J. and Tayler, K. 2003. ‘Decentralised Wastewater management in Periurban Areas in Low-income Countries’, Environment & Urbanization, 15(1): 75–90.

Rattan, R.K., S.P. Datta, P.K. Chhonkar, K. Suribabu, and A.K. Singh. 2005. ‘Long-term Impact of Irrigation with Sewage Effl uents on Heavy Metal Content in Soils, Crops and Groundwater: A Case Study’, Agriculture, Ecosystems and Environment, 109(3–4): 310–32.

Rohilla, S.K., P.S. Datta, and S.P. Bansal. 1999. Delhi’s Water and Solid Waste Management: Emerging Scenario. New Delhi: Vigyan Prasar Publications.

Sen, A. 1999. Development as Freedom. New York, NY: Alfred A Knopf. Sharma, S., I. Singh, and J.S. Virdi. 2003. ‘Microbial Contamination of Various

Water Sources in Delhi’. Current Science, 84(11): 1398–99.

380 Vishal Narain

Sharma, N.C., P.K. Mandal, R. Dhillon, and M. Jain. 2007. ‘Changing Profi le of Vibrio Cholerae 01, 0139 in Delhi and Its Periphery (2003–05)’, Indian Journal of Medical Research, May.

Sharma, V.P. 2006. ‘Problems and Realistic Estimates of Water Related Diseases.’ Paper presented at the Conference on Health and Environment, New Delhi. 24–25 March.

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Zerah, M.H. 2000. Water: Unreliable Supply in Delhi. New Delhi: Manohar Pub-lishers.

17

Results of Unplanned ProgrammesDrinking Water and Sanitation System

in Bhaktapur, Nepal

PRACHANDA PRADHAN

Long before the advent of modern medical care, industrialised countries decreased their level of water-related disease through good water management….In developing countries, water-related disease

blights the lives of the poor. Dr Gro Harlem Bruntland, Director General, WHO, 2001

INTRODUCTION

BHAKTAPUR SUB-METROPOLIS, inhabited by 70,000 people, is located on a fl at elevated plateau at an average elevation of 1,337 m between Hanumante River in the south and Khasankhusing River in the north. Before piped water supply system was installed, people used wells, stone water spouts and ponds to collect water for drinking and other domestic needs. Natural springs or subterranean channels fed the water spouts which were artistically carved and installed in public places. Called dhunge-dhara, these water spouts were sensitive to environmental alterations and geological activity.

In the 1970s, the German government assisted the Bhaktapur Development Project (BDP). The fi rst phase of the project included restoration and conservation of the ancient temples and the old and traditional houses. In the second phase, the focus shifted to cleanliness and sanitation; setting up systems for drainage and sewerage treatment and oxidation ponds and sludge fi elds. This phase saw development of roads, pavements and toilets in individual houses. During this phase, water supply reached individual houses. Private toilets were connected

382 Prachanda Pradhan

to the drainage and sewerage system, which was linked to the oxida-tion ponds that were connected to the local streams at Hanumante and Khasyangkhusung. The wastewater treatment component of the programme did not function well right from the beginning. The sewers were always clogged. Eventually, the programme became incongruous and failed to meet the needs of local people. The farmers diverted the wastewater to farmlands by breaking the sewerage pipelines.

This chapter attempts to analyse the adverse impact of an ineffi cient water supply and sanitation system on public health. It examines how improper functioning of infrastructure for maintenance of water quality, weak regulatory mechanism adopted by concerned agen-cies and non-compliance of sewerage disposal standards eventually resulted in severe health hazards for the people. It also highlights the lack of coordination among government agencies resulting in non-compliance of water quality standards and wastewater disposal proce-dures causing health hazards to the inhabitants of the area.

EVOLUTION OF THE WATER SUPPLY SYSTEM IN BHAKTAPUR

The importance of Bhaktapur lies in the fact that it is very strategi-cally located. It lies east of Kathmandu, the capital of Nepal, and was on the trade route to Tibet in the medieval period. It has rich cultural heritage and is home to superb art and architectural marvels (Map 17.1). It was known as the commercial gateway of the eastern region of Nepal (Kirkpatrick 1811).

Bhatkapur city is rich in water heritage. There are dozens of stone water spouts built during Lichchhavi and medieval periods. There are still 83 stone spouts, 34 ponds and 277 dug wells (Becker–Retterspuch 1995, Khaniya 2005). Due to Bhaktapur’s higher eleva-tion, groundwater through dug wells and spouts was exploited during the Lichchavi period in the 12th century. The Archeological Survey of Nepal identifi ed the water spouts of Lichchavi period—Tulutulu Hiti, Gaha Hiti of Glomadhi, Dhauwa Hiti, Baku Hiti and Bhindhyo Hiti. The ancient water spouts were constructed deep in the ground so that they connect to the aquifer source (Munakarmi 1993).

Results of Unplanned Programmes 383

Map

17.

1:

Loca

tion

of B

hakt

apur

Tow

n


In 1679, under the reign of King Jitamitra Malla, water for drinking and irrigation purposes in Bhaktapur was sourced from an irrigation channel. The channel directly fed into the water spouts, wells and multi-purpose ponds including groundwater recharge (Paudyal 1972). In 1895, piped water was supplied through public stand posts (Subedi 2004). Despite the provision of public stand post for drinking water supply, their coverage was limited. So people continued to use dug wells, stone water spouts and ponds for drinking water supply.

During the 16th century, Bhaktapur was the capital of the Kathmandu Valley Kingdom. Special provisions were made to strengthen drinking water supply through stone spouts. Malla King Jitamitra Malla constructed Raj Kulo (Royal irrigation system) in 1678 from the Mahadev River to bring water to Bhaktapur town and lowlands around it.

Water from this irrigation system started to recharge groundwater that increased the water table level thereby maintaining the continu-ous fl ow of water in stone spouts and wells. Many new stone spouts constructed during the Malla period were close to the surface area of Bhaktapur township. In a way, Raj Kulo was a multi-purpose irriga-tion system and became the lifeline of Bhaktapur township. In order to ensure the continuous fl ow of water in the drinking water system, religious and social regulations were announced by King Jitamitra Malla and the canal water supply was linked to the golden water spout located at the king’s palace. The temple and guardian goddess Taleju were washed with the water from the golden spout. This religious ritual reinforced the fl ow of water in all stone spouts. The king also issued an edict in 1683 stating that it was an obligation for the people to maintain the irrigation channel. The canal water was diverted for irrigation purposes only after the need for drinking water was fulfi lled (Paudyal 1972).

In 1895, piped drinking water, only for public stand posts, was introduced in Bhaktapur town. Bir Shumsher, prime minister between 1885 and 1900 constructed the piped water supply system for Bhaktapur tapping the Mahadev River which was also the water source of Raj Kulo (Subedi 2004).

However, the 1934 earthquake destroyed the basic water infra-structure and the canal became dysfunctional. In the 1980s, private


connections for water supply were made available through the BDP (Map 17.2). When a water supply system is installed for the public, there is a need to establish a safe disposal system for wastewater as well. Before the 1970s, there was no proper sewerage system. Basic drains were built to discharge the fl ow of kitchen wastewater and rainwater. Wastewater from the drains was used for irrigation in the lowland farms. Before the launch of BDP, the town had only community toilet systems. With the introduction of private water supply connections and construction of toilets in individual households, establishment of the sewerage system became necessary and was installed gradually.

It is a matter of concern that despite the progress made in the fi eld of water supply, the level of water-related sickness continues to affect the public. In Bhaktapur’s case this is primarily due to improper wastewater disposal system and lack of provision for main-taining quality water supply system. The records of patients in the Bhaktapur District Hospital (Table 17.1) sheds light on the extent of health crisis. In fact, patients treated in both Bhaktapur Hospital and Sidhi Memorial Children’s Hospital in the same town indicate the prevalence of a large number of water-borne diseases among all categories of population during 2006–09. At the national level, it is reported that 7–10 per cent of total deaths in Nepal were attributed to water-borne diseases, and a large number of them were of children (Pandey 2006, WHO 2006).

MODERN WATER SUPPLY SCHEME IN BHAKTAPUR Location of the Scheme

Mahadev Stream, the only surface source of drinking water in Bhak-tapur town, originates in the hill of Mahadev Pond at the elevation of about 2,100 m/ mean sea level. It is 5.4 km northeast of Bhaktapur. The fl ow in the Mahadev Stream is derived from perennial springs. During the dry season, all the water from this stream is diverted to Bhaktapur. Thus there are no opportunities to augment water sup-ply from this source in the dry seasons. The catchment of Mahadev Stream upstream of existing intake site has been protected as the

386 Prachanda PradhanM

ap 1

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Bageshwari Reserve Forest. The modernised reservoir under the BDP at Bansbari comprises of a renovated intake weir at the Mahadev Stream. This modernised scheme serves all the wards of the Bhaktapur sub-metropolis’s core area and partly the Sipadole and Katunje area of outer Bhaktapur town. It also caters to the local irrigation needs. In order to control the sediment fl ow, a gabion check dam across Mahadev Stream, 33 m upstream from the weir, was constructed in 1984. This has reduced the sediment fl ow and also prevented damage to the structure from boulders.

System Maintenance and Water Quality Management

The existing water supply network is operated and maintained by the Nepal Water Supply Corporation (NWSC), Bhaktapur Branch Offi ce. Maintenance works include cleaning the intake, reservoir, treatment plant, pipelines and other miscellaneous activities. The water treat-ment involves two stages—primary and fi nal. While primary treatment consists of mixing, coagulation, fl occulation and sedimentation, the fi nal stage includes fi ltration and disinfection.

Water Supply and Sewerage in BDP

The initial concept of BDP was comprehensive renewal and develop-ment of the city. The activities under the fi rst phase (1974–76) focused on restoration of ancient buildings around the Dattatreya areas under the supervision of Department of Archaeology of Ministry of Edu-cation. In the second phase (1976–80) while restoration continued as one of the core activities, other programmes like constructing an infrastructure for regular water supply to homes, building drains, roads and pavements also began under the guidance and supervision of the Ministry of Public Works and Transportation. Economic activities like establishment of handicraft centres also started (Saha 2003).

Expansion of Water Supply System in Second Phase (1976–80)

During the second phase, renovation to increase the capacity of the existing water supply system was initiated. Technical survey and construction supervisions were conducted by the local engineering


consultancy companies. With an aim to improve the environment of Bhaktapur, the water supply system was expanded and private connec-tions to individual households were given. New high density polythene (HDP) pipes were laid out in the eastern part of Bhaktapur for future expansion of the system. House owners were encouraged to construct individual toilets and subsidies were provided as an incentive to do this. Once people started investing in building private toilets, the BDP had to connect the toilets to a proper sewerage system. While the sewerage system was designed and constructed within six years (1974–80), BDP did not bother to consult local people on alternatives to the sewerage system. Consultation could have prevented the installation of toilet systems and septic tanks that used a lot of water.

IMPACT OF EXTENDED WATER SUPPLY The extended water supply and improvement in the source and distribution lines increased the number of private connections in the area. The total number of taps distributed to the private households was 6,889, along with 235 public stand posts (Nepal Consult and CEMAT 1997). For six months, beginning July to January of every year, the water supply to Bhaktapur from Bansbari is 5,500 m3/day, and from February to June, the quantity decreases to 3,000 m3/day. In lower Bhaktapur, water supply is provided from deep tube wells of Bode-Thimi. Despite the complex system put in place, water sup-ply in Bhaktapur remains erratic. Inhabitants get supply sometimes for two hours and sometimes for 10 hours. During the dry season, February–May, many taps stay dry, forcing people to use water from stone spouts and dug wells.

In a survey of water use conducted in Bhaktapur in 1997, it was revealed that 46 per cent of the people still use water from dug wells and around 10 per cent tap stone spouts. The survey also showed that 22 per cent consumers have suffi cient water supply, 23 per cent have insuffi cient water supply and 13 per cent get no water at all (Nepal Consult and CEMAT 1997).The construction of sewerage pipelines has contaminated and polluted the underground water aquifer that feeds water to the dug wells and stone spouts. The water loss due to defec-tive service connection, cracks in pipes and joints and unauthorised


connections from polyethylene pipes, is 2.89 million litre a day, which is about 43 per cent of the total water supply (Nepal Consult and CEMAT 1997). To extend the area of water supply, the BDP laid polyethylene pipes but the people made unauthorised openings in the pipes and connected the supply chain to their homes.

Due to cracks and leakages and unauthorised openings pollutants often entered the pipes. When the water supply is stopped, the pipes become empty and the stagnated water re-enters the pipes through cracks causing pollution in the water supply system. The treatment plant at Bansbari comprises of a sedimentation tank, coagulation–fl occulation tank, sand fi lter, chlorination unit and a reservoir. The treatment plant is not adequate to treat water to the required standards (Nepal Consult and CEMAT 1997). The water treatment condition described in the report of 1997 still continues and no improvement has taken place. The fl occulation tank, constructed in 1985, does not function. A gas chlorination unit was installed in the building near the reservoir intake chamber in 1985. The unit is put into operation only intermittently, depending on the availability of chlorine gas. Currently, chlorination is carried out with bleaching powder, which is mixed with water in a basin located in the reservoir according to the information provided by the in-charge of Bhaktapur Water Sup-ply System in 2009.

WATER SUPPLY SYSTEM CREATES HEALTH CRISIS The records of patients in the District Health Offi ce, Bhaktapur District Hospital (Table 17.1) shed light on the extent of the health crisis. In fact, water-borne diseases treated in both Bhaktapur Hospital and Sidhi Memorial Children’s Hospital in the same town indicate the prevalence of a large number of water-borne diseases among all categories of population during the period 2006–09. At the national level, it is reported that 7–10 per cent of total deaths in Nepal were attributed to water-borne diseases, and a large number of them were of children (Pandey 2006, WHO 2006).

The Siddhi Memorial Children’s Hospital, Bhaktapur reported that the hospital treated 3,310 children for water-borne diseases in 2008. Similarly, the District Health Offi ce, during an interview, informed


that 10,874 water-borne diseases were reported to the offi ce during 2008. Cases of deaths caused by water-borne diseases also came to light during this period.

THE SEWERAGE SYSTEM

Sewage pipes were laid out in different parts of Bhaktapur sub-metropolis with the aim to connect them to toilet outlets and to col-lect surface rainwater. Two oxidation ponds were constructed at two locations. The eastern part of Bhaktapur has ponds where wastewater is treated by electrically operated aerators in 1975s. After treatment, water was released to Hanumanghat River. In 1985, a second oxidation pond of 1.0 mld was constructed at Sallaghari, to treat wastewater from southern part of Bhaktapur. Sewerage from the northern part was also connected to the pond of Sallaghari. Two pipelines were constructed, one to carry the sewerage by gravity fl ow and the other to lift the sludge with the help of a pump near the Bhaktapur Campus. This sewage would then be lifted by electrically driven pump at the mouth of the pond at Sallaghari. Three electrically operated aerators/blowers were installed in the ponds for treatment of wastewater. Aerated ponds were constructed in Hanumante and Sallaghari, just before the treated sewerage is discharged to Hanumante River. Some of the features of the wastewater treatment plants are given in Table 17.2.

Certain components of the project, like the new sewerage system, did not work. In fact, both the treatment plant and the sewerage system did not work effi ciently, largely due to technical issues, lack of skilled personnel, budgetary limitations, lack of managerial capac-ity to monitor the systems, and fi nally, lack of public awareness and non-cooperation towards the implementation of the project.

Table 17.1: Water-borne Diseases Treated in Bhaktapur Hospital, Bhaktapur

Year Cholera Typhoid Dysentery Gastro-enteritis Jaundice Total

2006 – 72 – 68 2 1422007 – 93 – 103 9 2052008 13 61 7 55 9 1452009until June

1 56 1 46 17 121

Source: Bhaktapur Hospital (2009).


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BDP is a donor-driven project which had easy fl ow of funds at the initial stage of implementation of the programmes designed by expatriate technical manpower. There has not been serious technical planning by their Nepalese counterparts from the sustainability and managerial perspectives. Users were hardly consulted during fi rst and second phases. None of the wastewater treatment plants are in regular operation in Kathmandu Valley. After the project period was completed, resources dried up and the programme could not receive adequate budgetary support and manpower.

Wastewater management has been given low priority in the project in water supply and sewerage management. None of the wastewater treatment plants constructed during the project work well. Lack of skilled operators, adequate electricity supply, lack of timely mainte-nance of the machinery and pumps further impacted the functioning of the system. Due to lack of awareness among local people and con-fl ict of interests among farmers in the adjoining areas, the sewerage system and oxidation ponds were made non-functional. Bhaktapur residents put all kinds of materials, including plastic bags, jute bags and stones in the sewerage pipelines, thereby clogging the drains. Along the farming area, both around Hanumante and Byasi, farmers drilled holes in the drainage pipes to divert sewerage water into their vegetable fi elds (Rutkowski et al. 2007).

ADVERSE IMPACT OF SEWERAGE AND OXIDATION PONDS IN BHAKTAPUR

The traditional city of Bhaktapur was served by several water spouts, wells and ponds. These were fed by a well-developed watershed man-agement system, as well as an underground network of channels known as Raj kulos. The digging and installation of underground drains at the initial stage led to blockage of this network at several points, leading to the drying up of several spouts. The mixing of solid waste with the wastewater created problem of blockages due to insuffi cient gradient in the system (Parajuli et al. 1986).

River Hanumante has for centuries been the site for ritual bathing and a source for irrigation and other water usages. Three cremation sites are also in use around the river even at present. After cremation,


the family members of the dead person has to bathe in the river according to the tradition. But instead of bathing in the river, they go somewhere else. Since it has become an urban gutter, its religious and cultural prominence afe lost, and its environment polluted (Prajapati 2001).

Some of the reasons for the death of the river are:

1. Sewerage drains are constantly clogged. Independent outlets were located in various parts of the town and sewage from these outlets was discharged directly into the river (Saha 2003).

2. Households without sewerage facility constructed toilets with septic tanks that overfl owed directly into the river.

3. During the time of drain construction, many aquifers were disturbed. Leakage in drains polluted the underground water, resulting in health hazards to people using drinking water from stone spouts and dug wells.

The farmers’ needs for irrigation water from sewerage pipes proved to be stronger than their concern for health and hygiene, apparently due to their poor knowledge on health and sanitation issues related to wastewater irrigation. The farmers were desperate for getting water for irrigation and were of the view that the installation of the combined sewerage system deprived them of their traditional source of irriga-tion water for their fi elds. To access water for irrigation, the farmers blocked the main sewer pipe near manholes and directed the fl ow towards their fi elds (Joshi and Pradhan 1983). This practice eventu-ally led to the failure of the sewerage system. The use of wastewater for irrigation is common practice in many peri-urban areas (Pescord 1992). Crop yields are higher when wastewater is used as it contains not only water but crop nutrients like nitrogen and phosphorus. However, the use of wastewater for irrigation has its share of risks, as it facilitates transmission of excreta-related diseases. The World Health Organization (WHO) studies have confi rmed that the transmission of intestinal nematode infection, both to those working in the wastewater irrigated fi elds and those consuming vegetables grown in the fi elds, and also transmission of faecal bacterial diseases like Diarrhoea, Dys-entery, Typhoid and Cholera, is inevitable. The WHO recommends


that only treated wastewater should be used for crop irrigation, and treated wastewater quality has to be within limits of microbiological quality guidelines (WHO 1993). These standards are not followed in Bhaktapur. Water Supply and Sewerage offi ce has priority only for drinking water.

INTER-AGENCY ROLE IN PREVENTING HEALTH RISKS

National Scenario on Water Supply and Sanitation in Nepal

It is important to note that physical infrastructural development alone in establishing a water supply system cannot meet the health protection standards. It is found that water related diseases are not only the leading cause of morbidity and mortality worldwide, but the spectrum of disease and incidence of water-related microbial is actually increasing.

In order to address these problems, a mechanism has to be put in place for risk assessment, establishment of regulation for water quality performance, monitoring the water quality, disposal of wastewater and provision of fi ltration and disinfection technologies to prevent pathogens. The question is how much disease can be prevented through increased access to safe drinking water and adequate sanita-tion through better water management and better hygiene? Good water management includes improved methods of surveillance, epi-demiological studies and advanced methods of diagnosis which allows detecting the new strains of disease.

It is reported that almost 1/10th of the global disease burden, specially in developing countries, can be prevented by water, sanita-tion and hygiene intervention. The economic return of investment in improved access to safe drinking water is almost 10-fold (Pruss-Ustum et al. 2008)

The Millennium Development Goals (MDGs) target to halve the number of people without access to drinking water and sanitation facility by 2015. To realise the MDG on water supply and sanita-tion, the Government of Nepal (GoN) has prepared an intervention package (Table 17.3).


Department of Water Supply and Sewerage

The Department of Water Supply and Sewerage (DWSS), which comes under the Ministry of Physical Planning and Construction, is responsible for meeting the national target for water supply and sanitation. In 2005, the ministry promulgated the National Standard of Water Quality (NSWQ), and released the manual to implement NSWQ (Table 17.4).The manual suggests that NSWQ is to be maintained by the concerned supply agency. In case of Bhaktapur, it is the responsibility of Kathmandu Valley Drinking Water Supply Company Ltd. The surveillance responsibility is given to the Min-istry of Health and Population. The Ministry of Education is also made responsible to create public awareness by incorporating health and sanitation in the curriculum of primary and secondary level courses. Courses on environmental education, with a component on safe drinking water, have been incorporated at the primary level curriculum.

Surveillance and Quality Control

In 2005, NSWQ assigned the responsibility of surveillance and quality control to the Ministry of Health and Population. In order to ensure security of public health, the duel approach of differentiating the roles and responsibilities of service providers from the authority responsible for independent supervision of drinking water quality is adopted.

The NSWQ (GoN 2005) provided that (a) a national agency will provide the framework of targets and standards that a supplier would have to comply, (b) the agency supplying water will comply with safe

Table 17.3: Interventions by GoN to Achieve MDGs

Interventions Activities to be Undertaken

1. Water supply infrastructure2. Sanitation infrastructure3. Sewerage treatment4. Solid waste anagement5. Hygiene education

Provision and operation of infrastructureConstruction and operation of toiletsConstruction and operation of wastewater treatment plantsSafe collection and disposal of solid wasteAwareness campaign


Table 17.4: National Standard of Water Quality

Classifi cation Parameter Maximum concentration limit

Physical Turbidity pHcolourtaste and odourTotal dissolved solids (TDS)

Electrical conductivity

5 (10) NTU6.5–8.55 (15) TCUTolerable 1000 mg/litre

1500 µS/ cm

Chemical IronManganeseArsenicCadmiumChromiumCyanideFluorideLeadAmmoniaChlorideSulphateNitrateCopperTotal hardnessCalciumZincMercuryAluminiumResidual chlorine

0.3 (3) mg/litre0.2 mg/litre0.05 mg/litre0.003 mg/litre0.05 mg/litre0.07 mg/litre0.5-1.5 mg/litre0.01 mg/litre1.5 mg/litre250 mg/litre250 mg/litre50 mg/litre1 mg/litre500 mg/litre200 mg/litre3 mg/litre0.001 mg/litre0.2 mg/litre0.1-0.2 mg/litre

Microbiological EcolabTotal coli form

0 MPN/100ml0 (95% sample) MPN/100 ml

Source: National Standard of Water Quality (2005).Note: There are provisions for testing the quality of sample water in a government-

approved or government-owned laboratory. Surveillance and supervision is done by the concerned ministry as well as by the Ministry of Health and Population. At the time of commissioning the drinking water project, sanitation and health concerned plan is to be given to Ministry of Health and Population.

drinking water delivery norms and (c) a surveillance agency will be responsible for independent surveillance through periodic audit of safety features and verifi cation testing. The Ministry of Health and Population, supported by district and fi eld offi ces, is assigned the


responsibility of effective surveillance for maintaining water quality. Interview with the offi cials at the Ministry indicate that even as late as early 2010 the ministry had not undertaken surveillance responsibil-ity as mentioned in the manual of NSWQ to ensure water quality. The ministry does not even have a dedicated unit to undertake this responsibility as part of public health safety.

Water Supply Agency at Bhaktapur

The water supplier is responsible at all times for delivery of quality and safe drinking water. The supply agency is to take responsibility of water resource management for prevention of microbial and chemical contamination. Hence, it is the responsibility of the water supply agency at Bhaktapur to manage water treatment plants and monitor the quality of water at reasonable intervals. Bhaktapur sub-metropolis has witnessed frequent change of drinking water management agencies. The maintenance of reservoir, transmission lines and supply stand posts was the responsibility of pani goswara (water offi ce) that was operational till 1974. Afterwards many organisational changes took place until the Kathmandu Valley Drinking Water Supply Company Ltd took over in 2009. Currently, it comes under company manage-ment to ensure the autonomy of the operation.

The responsibility of regular evaluation of the quality of drinking water lies with the water supply agency. A report on the evaluation of water quality has to be made available to the District Public Health Offi ce regularly. It is the responsibility of the Ministry of Health and Population to inspect the water supply facilities and make sure that water supply is within the parameters stated in the NSWQ Manual (GoN 2005). The Ministry of Health and Population is also respon-sible for curative and preventive healthcare. Hence it has to make efforts to reduce waterborne diseases by establishing a monitoring system as per the NSWQ Manual (GoN 2005).

Unfortunately, the ministry did not even have a dedicated unit until early 2010 for monitoring and supervision of the drinking water quality. The ministry’s Department of Epidemiology becomes periodically active when water-borne diseases occur. The water quality monitoring reports are not regularly made available to the District Health Offi ce


by the service provider, and there is no system to analyse these reports by the Ministry of Health and Population. In Nepal, drinking water is considered to be an infrastructure programme, and not belonging to preventive health.

The offi cials from Bhaktapur Water Supply Offi ce reported during an interview in February 2009 that only bleaching powder and alum are mixed in water to purify it at the reservoir point. It is reported that the water supply offi ce undertakes Free Residual Chlorine (FRC) checking at two or three taps every day, with the accepted standard being 0.2 to 0.5. If the content is within the range, it helps elimi-nate bacteria in water. If it goes above 0.5, it can cause many health hazards including cancer. This check helps assess the quality of bleach-ing powder and alum in water and adjustments are made according to the test results. But checking only two or three consumers’ taps every day does not conform to the procedure of sample checking prescribed in the NSWQ Manual. The water offi ce in Bhaktapur does not men-tion about the physical, chemical or biological tests done to assess the quality of water. The District Public Health Offi ce and the Ministry of Health and Population also seem to be inactive in maintaining surveillance of the quality of water supply in Bhaktapur.

It is found that drinking water monitoring is done by the water supply offi ce. However, about 40 per cent of the people in Bhaktapur sub-metropolis are still dependent on dug wells and stone spouts for their water supply. The quality of such water sources is not monitored by any agency.

The water supply company also has to take care of the sewerage management. However, what has been witnessed since the mid-1980s is sewerage mismanagement. Sewerage has become the source of health risk among the farming community, consumers of vegetables grown out of sewerage irrigation and population of the surrounding area. Agencies are in place and regulations are provided but they have not been implemented.

Role of Bhaktapur Sub-metropolis in Water Supply and Sewerage Management

Bhaktapur sub-metropolis is one of those municipalities in Nepal which has been quite effective in implementing long term and short term programmes. The political leadership of Bhaktapur


sub-metropolis has played a dynamic role (Hachhethu 2004) since 1990s. The Local Governance Act of Nepal, 1999 (GoN 1999) empowers the local bodies like the Bhaktapur sub-metropolis to undertake water supply and sewerage programmes. The water supply and sewerage system can be well-maintained by the sub-metropolis. The Bhaktapur sub-metropolis has asked the concerned agency of the government to hand over the drainage management system to it saying they would manage it. Several meetings have already taken place between the government and the Bhaktapur sub-metropolis to identify the mode of transfer and resource mobilisation for manage-ment. The government at one point agreed to hand over these sewer-age and treatment plants to the Bhakatapur sub-metropolis but the proposal was fi nally rejected and the management of sewerage was given to a private company on contract. Currently, water supply and sewerage management is the responsibility of the Kathmandu Valley Water Supply Company.

COMMUNITY PARTICIPATION IN HEALTH RISK PREVENTION

Public health awareness campaigns are regularly organised at the community level by the Bhaktapur sub-metropolis. It has established three public health centres, through which the awareness campaigns are organised for the local people. The campaign includes messages like ‘Boil water before you drink’, ‘Wash your hands and feet after using the toilet’, and so on. Pamphlets containing information about safe drinking water and sources of diseases are distributed to the inhabitants of Bhaktapur. Ward committees, local clubs and CBOs are mobilised to intensify the public health awareness campaign.

In order to keep the environment clean in Bhaktapur, the sub-metropolis has adopted the policy of encouraging local people to construct private toilets inside their homes. An individual who is willing to construct a private toilet is given a subsidy of US $ 250 by the Bhaktapur sub-metropolis. It is mandatory to include toilets in new house constructions. They have the choice of connecting the toilet outlet to the sewerage system or construct their own septic tanks, depending on the location of the houses. However, the sewerage system has not improved causing further health hazards.


CONCLUSION

Good water management can save lives while poor water management can damage and harm them. Large-scale water supply system is not just about the physical infrastructure but includes a national drinking water policy, national standards of water quality, surveillance for the maintenance of the water quality, water management regulations, water supply monitoring, selection of a responsible supply agency, safe wastewater disposal, well-equipped laboratory for water qual-ity testing, community participation and a public health awareness programme.

Besides, availability of water at the source and construction of diver-sion weir, reservoir and transmission lines, the legal, social and health implications also need to be considered at the initial stage itself. An integrated approach of utilising all available of sources of water and their proper management would have better water supply system in Bhaktapur. Along with water supply, wastewater disposal mechanism appropriate to the place has to be considered during the planning of the water supply system.

The sewerage system in Bhaktapur has caused an adverse impact on Hanumante River that has degenerated into an urban gutter, vio-lating the environment protection laws of Nepal. This clearly shows the failure of the choice of technology, non-implementation of the existing laws and inactivity of the concerned agencies like the Water Supply and Sewerage Company and Ministry of Health and Popula-tion. The users are also to blame for improper utilisation of facilities and destroying the sewerage system. In order to allow wastewater irrigation, outlets to divert wastewater to the farms were provided by the water supply agency, much against the standard set by WHO for wastewater irrigation.

It seems that the Ministry of Physical Planning is geared to under-take only the physical infrastructure construction for water supply and the Ministry of Health and Population is not equipped to under-take the responsibility of water quality maintenance. A number of institutions share the responsibility for water quality maintenance. None of them seems effective. It is a situation caused by political instability where no one is in charge of the responsibility and people


are left on their own. The new company created recently is also neither making profi t nor giving service to the clients.

The case of Bhaktapur water supply system refl ects a microcosm of real socio-political situation that prevails in Nepal. The consequences of institutional failures, non-compliance of regulations and lack of surveillance to maintain water quality have contributed to serious health hazards. Water-borne diseases are frequently reported in the hospitals. Morbidity and mortality caused by water-borne disease are rampant. It is about 10 per cent as reported by WHO. Hence, targeting the relevant MDG in Nepal is not just about meeting the demands of water supply in this decade, but to prevent the high morbidity rate caused by water-borne diseases. After all, no responsible society can ignore 10 per cent death rate caused by one single source, that is water-borne diseases.

REFERENCES Becker-Retterspuch, R.O.A. 1995. Water Conduits in Kathmandu Valley. Delhi:

Vedama eBook (P) Ltd.Bhaktapur Hospital. 2009. Record Offi ce, Bhaktapur, June.GoN . 1999. Local Governance Act. Kathmandu: Ministry of Local Development———. 2005. National Standard of Water Quality Implementation Manual.

Kathmandu: Ministry of Physical Planning and Construction, Government of Nepal.

Hachhethu, K. 2004. ‘Municipality Leadership and Governance: A Case Study of Bhaktapur’ in L.R. Baral, K. Hachhethu, K. Khanal, D. Kuwar, and H. Sharma (eds). Local Leadership and Governance. Delhi: Adroit

Joshi, P. and P. Pradhan. 1983. Socio-economic Study of Irrigation Alternatives for Low-land Areas of Bhaktapur Town. Kathmandu: East Consult (P) Ltd.

Khaniya, G. 2005. ‘Governance Perspective on Water Management Practices: A Case Study of Bhaktapur City’, in P. Pradhan and U. Gautam (eds), Farmer Managed Irrigation Systems and Governance Alternatives, pp. 361–83. Kathmandu: Farmer Managed Irrigation Systems Promotion Trust.

Kirkpatrick, Colonel. 1811. An Account of the Kingdom of Nepal. London: W. Bulmer & Co.

Munakarmi. 1993. ‘Evolution of Stone Spouts’ (Nepali). Ancient Nepal. Kathmandu: Department of Archaeology.

Nepal Consult (P) Ltd. and CEMAT Consultants (P) Ltd. 1997. Design of Reha-bilitation and Extension Works of Bhaktapur Water Supply System. Kathmandu, Nepal.


Pandey, S. 2006. ‘Water Pollution and Health’, Kathmandu University Medical Journal, 4(1): 128–34.

Parajuli, Y., A. Saphalya, and K. Struchbeker. 1986. Bhaktapur Development Project: Experiences in the Preservation and Restoration of Medieval Town (1974–85). Kathmandu: Bhaktapur Development Project and GTZ.

Paudyal, B.N. 1972. ‘Royal Canal of Bhaktapur’, Purnima (Nepali language maga-zine), 4(January): 44–49.

Pescord, M.B. 1992. ‘Waste-water Treatment and Use in Agriculture’. FAO Irriga-tion and Drainage Paper 47. Rome: FAO.

Prajapati, U. 2001. ‘Sewerage Management: Bhaktapur Facing Severe Problem’. The Rising Nepal. March 17.

Pruss-Ustum, A., A.R. Bos, F. Gore, and J. Bartram. 2008. Safe Water, Better Health, Cost Benefi t and Sustainability of Interventions to Protect and Promote Health. Geneva: World Health Organization.

Rutkowski, T., S.L. Raschid, and B. Stephanie. 2007. Wastewater Irrigation in the Developing World: Two Case Studies from Kathmandu Valley in Nepal. Agriculture Water Management, 88: 83–91.

Saha, B. 2003. ‘Heritage Conservation and Planning: New Development in Bhak-tapur, Nepal’, paper presented at the International Symposium on Manag-ing Confl ict and Conservation in Historical Cities, 24–27 April, Annapolis, Maryland.

Subedi, R.R. 2004. Factual History of Nepal. Kathmandu: Sajha Parakashan.UNDP/Nepal. 2005. Millennium Development Goal: Managing Water Supply and

Sanitation, 2005–15. Kathmandu, p. 48.WHO. 1993. Analysis of Waste Water for Use in Agriculture: A Laboratory Manual of

Parasitological and Bacterological Techniques. Geneva: World Health Organiza-tion.

———. 2006. ‘Mortality Country Fact Sheet Nepal 2006’. Geneva: World Health Organization.

PART VI NATURAL DISASTERS,WATER AND HEALTH

404 Papreen Nahar et al.

18

Interrelation between Water,Health and Livelihood in Disasters

PAPREEN NAHAR, FARIBA ALAMGIR, ANDREW E. COLLINS, NIBEDITA RAY-BENNETT AND ABBAS BHUIYA

INTRODUCTION

BANGLADESH IS ONE of the most disaster-prone countries in the world because of its geographic location, climate and low-lying nature. Environmental disasters, such as tropical cyclones, storm surges, fl oods, tornadoes and droughts affect the country almost every year (Alam 1990, Rahman 1989). It has been argued that worldwide, including Bangladesh, the most signifi cant causes of the increase in the number and impact of disasters are poverty, inequality and land shortages which drive people onto much more marginal territory, increasing their exposure to natural hazards (Maskrey 1989, UNDP 1992, 2004, 2008).

INTERCONNECTION OF WATER, DISASTERS,HEALTH AND LIVELIHOOD

The common negative impacts of environmental disasters include increase in the incidence of communicable diseases, population dis-placement, increased exposure to hazards, lack of food and nutrition and mental health problems and damage to health, water supply and sanitation infrastructure (PAHO 2000). The World Health Organiza-tion (WHO) has established that there is a disease burden related to poor water, sanitation and hygiene (Rahman and Ahmad 1991) and has produced a methodology to estimate it (Fewtrell et al. 2005). In Bangladesh, fl oods, cyclones and droughts inevitably lead to water


problems, which in turn, lead to an increase in health problems (Choudhury et al. 2006, Zaman 1999). The leading cause of health problems as a result of environmental disasters are water scarcity and pollution. Water scarcity, excessive water and pollution are not only responsible for water-borne and water-related diseases, but also may have an adverse effect on the livelihoods of poor and rural popu-lations. Macro-level economic impacts due to disasters also ultimately affect people’s livelihoods. Dorosh et al. (2004) discussed how the 1988 fl oods of Bangladesh caused a decline in crop production, loss of assets and fewer employment opportunities.

Health impacts on disasters and disasters’ impacts on health vary between rich and poor, male and female, and depend on the nature of the disaster event (Nahar et al. 2010). The poor are the most vul-nerable to environmental hazards and disasters, which in turn ag-gravate their poverty. The poor and vulnerable experience the most severe health impacts in the following ways: Living conditions become unhygienic, sickness abounds due to poor nutritional status and treatment becomes unaffordable because livelihoods are hindered by the disaster (Elahi 2001, Edgeworth and Collins 2006, Maskrey 1989, WHO 2004). Loss of employment opportunities and price hikes after a disaster affect a household’s purchasing power. Both can affect food consumption (Baskett and Weller 1988). Shortage of food may have severe nutritional consequences, including starvation or micronutrient defi ciencies. In this chapter, we point in particular to the inter-relationships between water, health and livelihood in the aftermath of disasters.

PROBLEMS WITH WATER SUPPLY AND SANITATION

While disasters generally have an adverse effect on health increasing the risk of communicable diseases, it is no surprise that fl oods can potentially increase the transmission of infectious diseases through water (Few and Matthies 2006, WHO 2004). The relation between water, sanitation and transmission of diarrhoea is also well known (Briscoe 1981). In Bangladesh, this relationship becomes more im-portant after a disaster when many of the normal sanitary provisions

Interrelation between Water, Health and Livelihood 407

have been destroyed or disrupted (Kafi luddin 1991). Post-disaster, Diarrhoea epidemics are the most common disaster-related public health problems (Woodruff et al. 1990).

Major environmental events such as fl oods and cyclones may cause large, spontaneous or organised population movements, often to areas where health services cannot cope with the new situation. This leads to an increase in morbidity and mortality in resettlement areas. Pathogens in disaster-affected areas and population displacement both contribute to an outbreak of communicable diseases during or after a disaster. Disease vectors, such as mosquitoes and rodents, may have greater access to people who have lost their housing and are exposed to the environment or crowded together in camps (Noji 1997, Toole and Waldman 1993). The discontinuation of water services during and after a disaster can force people to use unclean water sources. A decrease in the quantity of water available may contribute to deteri-oration in personal hygiene and lead to increased transmission of diarrhoeal diseases including cholera and dysentery.

Kunii et al. (2002) found that the 1998 Bangladesh fl ood had a substantial impact on the health of communities, including com-municable diseases, lack of water supply, sanitation services and malnutrition. According to WHO Situation Reports on the fl ood of October of 2007, as many as 236,558 people were affected bydiarrhoea that caused 54 deaths in Bangladesh. The fl ood also gave rise to hepatitis and typhoid and to skin, eye and respiratory infections. The recommended source of domestic water in Bangladesh is tube wells (UNICEF 1987). A public tube well serves on the average 60 people in rural areas but as many as 123 in coastal areas (Mitra and Associates 1992). It was observed that during the cyclone and tidalsurge of 1991, most of the tube wells were damaged (MHFW 1992). This resulted in a severe shortage of water. Although surface water may be abundant and easily accessible for domestic purposes throughout most of the year, it becomes heavily contaminated with fecal matter and bacteria (UNICEF 1987) during fl ood.

Women and children are often the most vulnerable groups during a disaster. The responsibility of collecting water often falls on them. Women and adolescent girls can be vulnerable to sexual violence


or exploitation while accessing community water and sanitation fa-cilities among displaced communities (Rashid 1999). The wide range of impacts on health from environmental disasters is well documented, and the relationship between poverty and health is also well known and established (Edgeworth and Collins 2006). However, few studieswere conducted linking health, water and disaster in Bangladesh (BRAC 1999). One of the key factors that demands attention is the more precise nature of linkages between water and health in the aftermath of natural disasters, and their infl uence on livelihoods. This chapter, therefore, aims to better interpret those linkages, with specifi c reference to fl oods, droughts and cyclones, which are considered to be the most common disasters in Bangladesh.

METHODOLOGY

This chapter is based on a broader study, which aimed to defi ne ‘health security’ in the context of disaster resilience. In the broader study, mixed methods for data collection were applied using both qualitative and quantitative tools. A quantitative survey was conducted among 631 households based on pre-set questionnaires. For qualitative data, 32 in-depth interviews, 18 focus group discussions and 15 household participant observation exercises were done. The fi eldwork was designed and conducted by the International Centre for Diarrhoeal Disease Research (ICDDR), Bangladesh and the Disaster and De-velopment Centre (DDC) of Northumbria University, Newcastle, UK. The research design included eliciting indigenous knowledge. This pertained to three specifi c natural hazards addressed by this chapter, namely fl ood, cyclone and drought in relation to health. The study was carried out in three purposively selected disaster-prone rural areas in Bangladesh, that is Matlab (fl ood-prone), Chakaria (cyclone and fl ash fl ood-prone) and Nilphamari (drought-prone) (Figure 18.1). Among the respondents, there were equal mix of male, female, poor (having less than 50 decimals of land and depend only on menial labour) and non-poor. The fi eld work took place during 2007–2008. The data from the household surveys were analysed using Statistical


Package for Social Sciences (SPSS) and MINITAB as preferred and the qualitative data was translated, transcribed and coded usingAtlasti. This chapter is based mainly on qualitative data.

FINDINGS

Findings from the study that are addressed here are based on people’s perceptions of two broad themes—Health consequences of disasters and their impact on livelihoods, particularly with reference to water. Common environmental hazards mentioned by the respondents in this study subjects were fl oods, water stagnation, cyclones and other storms, drought, excessive rain, intense sun and fog.

Figure 18.1: Field Site Locations

Source: ICDDRB (archive).


PERCEPTIONS OF THE IMPACT ONHEALTH FROM DISASTERS

FloodsThe study shows that fl oodwater is a major cause of health problems in the study areas. Besides the lack of safe drinking water, it is also a reason for increased health risks and vulnerabilities. The respondents frequently mentioned diarrhoea, dysentery, typhoid and jaundiceas the main diseases caused by fl oodwater. Furthermore, if fl oodwaters remain for a long period, it leads to other health problems such as skin diseases, cold and cough and fever. Even when the water subsides, the ground remains soft, sticky and contaminated. The poor people, who do not own cots or beds, often catch colds from sleeping on the wet ground. In the case of old people and children, this causes pneumonia.Inhabitants are also vulnerable to skin diseases from walking in con-taminated water and mud. Snake bites are also a problem.

The study has shown that fl oodwater often becomes contaminated when latrines are fl ooded, forcing people to defecate in open further resulting in contamination of water sources. As one participant from Chakaria said, ‘The only way to be safe is to keep away from the water, which is impossible, because there is water everywhere.’ In the entire study area it was found that people are willing to collect safe drinkingwater far from their homes. They sometimes collect water from neighbours’ houses, schools or even other villages. In Chakaria, people reported that when fl oodwater began to rise, they collected and stored rainwater and water from unaffected tube wells in pots and pitchers. Even so, access to safe drinking water is not always possible during a fl ood and people are forced to use contaminated water, often resulting in health problems.

Women and children are especially vulnerable to risks of con-taminated water. Women report that even if they can manage to drink safe water they have to use fl oodwater for cooking, cleaning andlaundry. They also bathe in fl oodwater. Women complained of itching or skin infections on their feet. Some women believed this could be due to their exposure to contaminated water for long periods. Usually, the older women are responsible for collecting water because it is not socially acceptable for young women to venture far from their homes due to purdah. Some households, however, do not have older women and the duty falls on younger women and even children.


In Matlab, participants stated that many children die from drowningduring fl oods and expressed their concern regarding the safety oftheir young children during hazards. During a fl ood parents reported taking turns at night sleeping and staying awake to look after their children. One of the female respondents said, ‘My eldest daughter fell into the water but she survived.’

Droughts

The people of Domar in Nilphamari experience water scarcity as a result of drought. The main reasons for the scarcity are too much Sun—drought takes place in May and June—and the absence of open water bodies. It is said that water evaporates so quickly that it becomes diffi cult to irrigate crops during a drought. In addition, tube wells that people rely on for drinking water sometimes run dry. Droughts hit just when farmers are ready to harvest rice. They have to do heavy labour under the scorching sun. Lack of water during this time makes both irrigation and paddy farming diffi cult. The more the people are exposed to the elements and overworked, the more vulnerable they are to disease.

People perceive that exposure to Sun and lack of water are the main reasons for their vulnerability to diseases like diarrhoea, measles and small pox. In Domar, most of the poor people said that when it is very hot during the drought season they suffer from fatigue, and even faint due to heat strokes. The poor villagers suffer from viral fever and cough during the heat spells. Scarcity of water for irrigation hampers health in other ways as well. Participants explained that they face problem in washing the jute, an important step in processing, as it requires a huge amount of surface water. Working day and night with a scarce amount of water which has a bad odour from rotten jute, makes them sick. Both the non-poor and poor respondents pointed that the tension of having dry fi elds and their longing for rain disturb their peace of mind.

Cyclones

Since Chakaria is repeatedly hit by cyclones, the respondents men-tioned how these damage many houses, crops and trees. The riverand canal water become salty and contaminated after the cyclone.


Ponds and ditches become contaminated as well, and villagers depend on tube well water for drinking. As many tube wells also get damaged, people face diffi culties getting drinking water. The respondents par-ticularly mentioned the devastating experience of the 1991 cyclone.

Matlab was devastated by Cyclone Sidr in 2007 during our study period. Our observation data confi rmed that Sidr also damaged many houses, crops and trees. After the cyclone, the surface water became contaminated. Although both poor and non-poor accessed tube well water for drinking, they used surface water for all other purposes. Many of them often suffered from diarrhoea, dysentery, fever and cold after the cyclone.

PERCEIVED SEASONAL VARIATION OF HEALTH IMPACT

People’s suffering from different diseases is often also related to pat-terns of agriculture and related activities. There is a relationship be-tween the amount of work to be done in the fi eld and the suffering they experience from diseases that varies according to seasons. Table 18.1 shows the agricultural activities, environmental hazards and illness at different times of the year as mentioned by the respondents.

PERCEPTIONS OF THE IMPACT ON LIVELIHOODS The economic impact of disaster can be direct or indirect. The disasteritself can immediately damage crops, houses, infrastructure and industry, affecting people’s income. In the previous sections, it has been observed that the health consequences of a disaster often occur because of changes in water quality and quantity. The current study also shows that this ultimately impacts people’s livelihoods.

Assets for coping with disaster have been collected through a free listing exercise. The list included land, house, cattle, poultry, trees, and other materials and good health (shushtho shorir). This list was used to identify people’s perception of - important assets for coping with disaster. Through the ranking exercise it was revealed that almost all the participants perceive good health as the most important asset for coping with disaster. The poor respondents mentioned that their

Tab

le 1

8.1:

Agr

icul

ture

, Env

iron

men

tal H

azar

d an

d Il

lnes

s in

the

Stud

y A

reas

Beng

ali M

onth

Agri

cultu

ral

Activ

ities

Envi

ronm

enta

lH

azar

dIll

nesse

s

Boish

akh

(14t

h A

pril–

13th

May

)H

arve

stin

g Ir

i pad

dy

and

proc

essin

gW

inds

torm

(dhu

n)St

orm

(Bat

ash,

jhor

tufa

n)H

ail s

torm

(Pat

hor)

Extr

eme

sun

(Kor

a Ro

dh)

Dia

rrho

ea, d

ysen

tery

, ski

n di

seas

es,

mea

sles,

pox,

vom

iting

, typ

hoid

,lo

w fe

ver (

sham

shem

a jo

r)

Joish

tho

(May

–Jun

e)Si

mila

r as i

npr

evio

us m

onth

Win

dsto

rm

Stor

m H

ail s

torm

Ex

trem

e su

n

Dia

rrho

ea, d

ysen

tery

, ski

n di

seas

es, m

easle

s, po

x, v

omiti

ng, t

ypho

id, l

ow fe

ver

Asha

r(J

une–

July

)H

arve

stin

g ju

teFl

ood

Exce

ssiv

e ra

inSt

orm

Ince

ssan

t rai

n(S

him

shim

ani b

risth

i)W

ind

Dia

rrho

ea, f

ever

, col

d, d

iffer

ent w

ater

rela

ted

dise

ases

(pa

inna

osh

ukh)

Srab

on(J

uly–

Aug

ust)

Sow

ing

Am

anpa

ddy

Floo

dEx

cess

ive

rain

Stor

mIn

cess

ant r

ain

Win

d

Dia

rrho

ea, f

ever

, col

d, d

iffer

ent

wat

er re

late

d di

seas

es, e

ye in

fect

ion

(cho

kh o

tha)

Bhad

ro(A

ugus

t–Se

ptem

ber)

Wee

ding

Floo

ding

Wat

er lo

ggin

gIn

cess

ant r

ain

for 5

–7 d

ays w

ith

stro

ng w

ind

(Sha

tao)

Col

d, c

ough

, fev

er

(Tab

le 1

8.1

cont

inue

d)

Beng

ali M

onth

Agri

cultu

ral

Activ

ities

Envi

ronm

enta

lH

azar

dIll

nesse

s

Arsh

in(S

epte

mbe

r–O

ctob

er)

No

wor

kIn

cess

ant r

ain

Floo

ding

Wat

er lo

ggin

gIn

cess

ant r

ain

for 5

–7 d

ays w

ith

stro

ng w

ind

Col

d, fe

ver,

tons

il, c

ough

ing,

soar

s

Kar

tik(O

ctob

er–N

ovem

ber)

No

wor

kFo

od sc

arci

ty

Mon

gaH

unge

r (kh

ida)

Agra

haya

n(N

ovem

ber–

Dec

embe

r)H

arve

st a

nd p

roce

ss

Am

an p

addy

, pl

antin

g m

usta

rd

No

haza

rdC

old,

feve

r

Pous

h(D

ecem

ber–

Janu

ary)

Plan

ting

pota

to/w

heat

Dar

k m

ist (P

ala

pora

), co

ld

wav

eA

sthm

a, to

nsil,

feve

r, pn

eum

onia

Mag

h(J

anua

ry–F

ebru

ary)

Plan

ting

Iri (

Chi

na)

rice,

wee

ding

Ex

trem

e co

ld,

Mist

y fo

r day

sA

sthm

a, to

nsill

itis,

pneu

mon

ia

Falg

un(F

ebru

ary–

Mar

ch)

Plan

ting

toba

cco/

jute

Stor

mR

ain

Hai

l sto

rm

Col

d, fe

ver

Cho

itro

(Mar

ch–A

pril)

Har

vest

ing

toba

cco/

ju

te/w

heat

Exce

ssiv

e su

n (k

ora-

rod

)St

rong

win

dsto

rm (

jhor

tufa

n)H

ail s

torm

Dia

rrho

ea, d

ysen

tery

, ski

n di

seas

es, m

easle

s, po

x, v

omiti

ng, t

ypho

id, l

ow fe

ver

(Tab

le 1

8.1

cont

inue

d)


body is the primary tool used for their livelihoods. Therefore it is very crucial for them to remain healthy.

The non-poor also believed good health was important, because after a disaster they often needed to replant crops by themselves. Many labourers migrate to towns for jobs after a disaster, causing an increase in wages. The hard work of replanting requires good health for the owners and the labourers. The poor in their normal lives struggle for survival. When disaster occurs it creates even more struggle. As an old widow said:

I earn 50–60 taka (69 taka = 1 US dollar) per day while my son earns 70 taka per day doing farming labour. If someone gets ill then we will not have enough to eat, and we will fi nd it diffi cult to manage money to go to a doctor. We cannot afford medicines for long-term treatment. We can barely afford two pills for any kind of problem.

Another female respondent reported inability to see a doctor or buy food after a disaster. She said, ‘If the illness worsens, we go to a doctor after taking a loan.’

In Domar, one of the respondents was actually sick during the interview. It was discovered that he had returned from the doctor’s clinic without treatment because he did not have any money to pay for it. He was also unable to work in the fi elds because of his illness, which made it even more impossible for him to seek treatment. Another male respondent in Domar pointed out that the transport cost of getting to a doctor alone is too much. He said that the village doctor (quack or chemist) could be seen instead, for the price of the transportation to the professional doctor, and, therefore, preferred to visit the village doctor. When poor people get sick, they try to return to work as early as possible. One poor female reported:

As soon as I recovered from a fever that I got as a result of drought,I started working again. As I got a little more energy, I start working. It is only when I could not get up from the bed that I do not go to work. If I were healthier, then I would not have found it so diffi cult to work in the rain or during drought. If my health was good thenI would not get attacked by disease.

Poor people in each of the study areas mentioned that they worried about a sudden requirement of money for treatment. A woman in


Domar stated, ‘We do not have money to receive medical treatment, which increases our risks. If we go to the doctor, they do not give us medicine. If we had money we could go to the town to get proper treatment.’ Another woman in Matlab stated, ‘There are risks ofgetting ill during fl ooding. But it also becomes more diffi cult to go to a doctor because we often lack money as a result of the fl ood.’

EXPERIENCE OF CROP DESTRUCTION AND LOSSDUE TO FLOODS

In addition to cyclone, fl ash fl ood is also a common and recurring environmental hazard in Chakaria. When fl oods occur, no one can predict how much will water rise. Sometimes, water rises up to an arm’s length within an hour. The population under study at Chakaria mentioned that after heavy rain they witnessed scenes of stagnant water, muddy roads and children unable to go to school. In 2007, three consecutive fl oods occurred. The second fl ood was especially devastating. Water entered most of the households in the village, and in some households, water remained for four to fi ve days. Many non-poor households reported facing the loss of seedlings from the fl ooding which was planted during that time. For the poor fl ash fl ood has serious impact on livelihood since there is no work available during the fl oods.

The participants mentioned that cattle are crucial to their livelihoods. Sometimes, cattle get stranded by fl oods and drown. People also lose household belongings during fl ood, which further impacts their livelihoods. A common practice during fl oods is to put everything, including clothes, utensils, books, food, stove and even chickens and ducks on the machca or ‘oui,’ which is a kind of high bamboo platform (attic). There are signifi cant losses of assets when the water rises above the level of macha, because people then move in to the attic (if they have one) or the roof leaving behind their assets.

The non-poor households who own land, reported that it is a huge job to re-cultivate after a fl ood. Agricultural workers have to be hired, seeds have to be bought and the work supervised. They reported taking loans to fi nance re-cultivation and rebuilding of their houses after a fl ood. A non-poor woman in Chakaria stated:


There are risks of having crop failures if fl oods occur again. We sowed three bunches of seedlings of rice before a fl ood. But it was damaged in two days. Yesterday, we sowed the seedlings again. Each bunch of seedlings cost 300 taka. In 2007, we had very low yields because of fl ood. In 2008, we may suffer crop losses again.

Flood is a recurrent hazard in Matlab too. The respondents from Matlab mentioned that fl oodwater often enters houses and remains there for 15–20 days. Daily life becomes nearly impossible. Latrines become submerged, safe water becomes scarce, and feeding cattle and shopping for food becomes very diffi cult. Cyclone Sidr in 2007 destroyed rice fields and vegetable crops. The cyclone broughtknee-high water to agricultural fi elds. Non-poor farmers lost their harvest as well as the seeds for the next season. They then had to raise money to buy essential food items, as well as seeds and fertilisers for new crops.

EXPERIENCE OF CROP DESTRUCTIONDUE TO DROUGHT

Domar experiences multiple environmental hazards. These include drought, heavy rainfall, excessive heat in summer, cold spells in winter and storms. Each of these hazards has different impacts on crops. While heat and absence of rain often damage jute crops and hinder rice planting, excessive rainfall in the rainy season often damages rice crops.

Respondents from Domar reported that during summer when there is drought the common strategy to protect the crop is to irrigate the fi eld by using a mechanical pump. It takes 250–300 taka ($ 4) just to water half a hector (one bigha) at a time. Big landowners usually manage to save their crops through irrigation. However, those with small and mid-sized farms often fi nd it diffi cult to irrigate their land during droughts. Sharecroppers fi nd it particularly diffi cult to arrange the money for irrigation. They can sometimes manage to irrigate once or twice, but that is often not enough. At least a portion of their crops generally gets damaged if there is a drought. Small and mid-sized farm holders reported that they take loans to pay for irrigation.


Respondents also mentioned that during summer, due to thescarcity of water, the jute harvest often gets damaged. After harvesting, jute needs to be soaked in water in order to get soft and later washed. To save the jute harvest, the common practice is to lease a ditch or a pond, and fi ll it with water by using a mechanical pump. However, leasing a ditch or pond and renting the pump often costs a lot of money for a small farmer. For day labourers (half of our respondents) also there is scarcity of job. In these ways drought also causes economic loss for both poor and non-poor inhabitants.

EFFECTS ON THE POOR AND WOMEN

Since the poor do not have resources such as land or their own crops, they do not face loss of fi nancial capital from disasters though their sources of livelihood are at risk. In addition, environmental hazards and disasters can have a signifi cant impact on their incomes. If farmers face losses, then the employment opportunities for poor agricultural workers become scarce and women are the fi rst victims. One agri-cultural worker stated, ‘If the crop is destroyed, then it is a loss for both the landowner as well as for us.’

A respondent in Nilphamari, a rickshaw van puller, reported:

When people have a good harvest, they travel to different places and we have a good income. But when the harvest is small, or people face crop loss, then they do not go anywhere, and do not get hired for work. As a result my rickshaw is not used.

A poor farm labour in Domar said, ‘We suffer during droughts from lack of opportunity to work. During droughts, the landownersthemselves do everything, and they do not hire us.’

There are some lean periods when no work is available in the agri-cultural fi eld. There is often a food crisis during the lean season, known as monga (famine), the time between planting and harvest when there isno opportunity for employment for agricultural workers (Table 18.1). The lean season reduces the people’s access to income, which is a shock on their livelihoods. Monga is not a shortage of food, but a period of food insecurity due to lack of disposable incomes. Price hikes of food and other essentials are another characteristic of the period. Monga is


a recurrent hazard in the North Bengal region. It has been found that during the lean period, the poor often are forced to sell their labour in advance. In this way, they often lose the opportunity to bargain for higher wages during the harvest season. It was also found that during monga men from the village migrate to other parts of the country for work leaving their wives and children behind. The women mentioned that without any fi nancial resources they are forced to starve or semi-starve as there is no food or job available in the village and they have restricted mobility.

Most of the poor participants perceive their poverty as the main source of their vulnerability. They cannot even get credit in times of crises like disasters because they are poor. Excessive workload is also perceived as a major source of vulnerability. One poor labour woman of Domar represented most when she said that even when she suffered from Fever, she went to work with plastic sheets over her head in the rain. She believes that if she could stay at home and did not have to work in bad weather, then she would not be vulnerable to health problems. Fragile or dilapidated housing is also considered a source of vulnerability, particularly during storms.

The poor respondents also believe that their dependence on daily wages exposes them to vulnerabilities. In Chakaria it was found that poor rickshaw pullers work in bad weather to earn money, which often makes them ill. In Matlab, the inability to store enough food often makes the poor people feel vulnerable. The poor who do not own tube wells and latrines also feel vulnerable. The inability to get credit and the fear of not having money or food makes the poor vulnerable.

DISCUSSION AND CONCLUSION

This chapter has opened up an exploration of local people’s knowledge and perspectives on the inter-relatedness of disaster, water, health and livelihood. People’s knowledge is defi ned as ‘commonsense under-standings and personal experience, imbued with professional ratio-nalisations’ (Blaxter 2004: 46). Understanding the inter-relatedness of disaster, water, health and livelihood from people’s perspective is a challenge but is crucial because the community living everyday with poverty and disaster vulnerability are in a better position to rationalise their problems than ‘experts’ from outside.


In general, a majority of people in Bangladesh lack access to safe waterall of the time. Environmental disasters make the situation worse. This chapter shows that the most common environmental disaster events experienced by the people in Bangladesh, such as fl oods, cyclones and droughts, create water problems, and consequently health problems. The current study confi rms that the foremost factors for inducing health problems relate to water scarcity, excessive water or water pollution. The chapter shows that these are responsible for not only water-borne or water-related diseases, but also environmental impacts on livelihood security. Lechat (1979) mentions fi ve differentphases of disaster—non-disaster or inter-disaster, pre-disaster or warning, impact, emergency (also called the relief or isolation phase) and rehabilitation or reconstruction. These phases may last from just a few seconds to months, or even years. These are pervasive in many analyses of disasters (see, for example, multiple years of the International Federation of Red Cross and Red Crescent ‘World Disasters Report’) and in terms of disaster and development linkages(Collins 2009). One phase merges into the next (Cuny 1993). Specifi c medical and health problems tend to occur at different phases after the impact of disaster (WHO Chronicles 1980). It is also evident that the types of health hazards present depend on the nature of the envir-onmental hazard. While fl oods and cyclones give rise to water-borne diseases, droughts cause illness from lack of water or excessive heat.

Flood-related health effects have been extensively documented in public health literature throughout the world. These studies have shown that fl ood-specifi c mortality varies by country. In fl ood-prone Bangladesh, approximately 15,000 people are killed each year due to fl ood disasters (IFRC 1993). However, through this study we have noted some variation between sub-areas represented by contrasting types of hazards.

Flooding can spark communicable disease outbreaks because of the interruption of basic public health services and the overall deterioration of living conditions. Siddique et al. (1991) note that during fl oods underground pipelines may rupture, storage tanks may be dislodged, toxic-waste sites may over fl ow and chemicals stored at ground level may get released. However, there are examples of mass fl ooding where infectious disease has not been particularly more elevated than during


periods marked more by economic change. This was found by Collinsand Lucas (2002) in relation to ‘the great fl ood of Mozambique’ in 2000, during which period diarrhoeal disease cases were less than during the great epidemics of 1998. The explanations could not be proved but where evaluated as having been due to a mix of ecological, social and economic factors.

There is a need to assess and understand the impact of environ-mental hazards in their broader contexts. Part of that context is an understanding of the inter-relationship between water, health and livelihood during both periods of crises and periods of relative nor-mality from people’s perspective. The theme of viewing disasters in development and of getting development out of disasters, including its connection with health, is explored in some detail by Collins (2009). However, much remains to be converted into policy and practice in the world’s most regions at risk. Arguably, in relation to water, health and livelihood in an interconnected world of climate and economy change, the entire planet is obliged to engage in facilitating the solu-tions of the future.

More locally, despite repeated disasters, the healthcare system in Bangladesh has yet to develop disaster-responsive services. Moreover, the existing health infrastructure may also be destroyed in a disaster. The current study shows the extent of ongoing suffering and helpless-ness of diseased people who are particularly affected post-emergency as a result of a lack of proper health services. In 1991, a cyclone inBangladesh is estimated to have damaged a total of 431 health institu-tions in 80 upazilas in 15 districts, to varying degrees (MHFW 1992).

The experiences and perspectives of the respondents exemplifi ed the impact of health due to disaster and underdevelopment as ultimately affecting people’s livelihoods. Due to this, people suffer from both direct and indirect economic loss. Due to illness from environmental events, people lose their productivity and are deprived of income, suffering from indirect economic loss. The chapter reveals that water problems as a result of disasters not only creates health hazards but also affects people’s primary method of earning money, cultivation and other daily activities, irrespective of gender or socioeconomic status in Bangladesh. However, it is always the vulnerable who suffer most from any hazard, in this case women and the rural poor. Peoples’ experiences


and perspectives from the contrasting areas of Bangladesh confi rm a forward impacting relationship from environmental change and the altered water related threats to health equilibriums and to livelihood, which compounds further on health. However, the improvement of health may offset this process.

In order to develop a disaster responsive service in Bangladesh it is important to take these experiences and perspectives of local people into consideration. As Rice et al. (1994) and Phillimore and Moffatt (1994) mention the best solutions are achieved by adopting more bottom–up rather than top–to-bottom approaches. This study suggests that everyday experiences of living with poverty and depriva-tion during and after disaster is fundamental to any analysis of public health in this region. Listening to communities in order to address their interpretation of these problems could provide further insights to policymakers as well as become an empowering process for the communities involved.

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Report of PACT Bangladesh/PRIP and Association of Development Agencies in Bangladesh, Dhaka.

Baskett, P. and R. Weller. 1988. Medicine for Disaster. London: Wright.Blaxter, M. 2004. Health. Cambridge: Polity Press.BRAC. 1999. Experiences of Deluge: Flood 1998. Bangladesh Rural Advancement

Committee monograph. Dhaka: Bangladesh Rural Advancement Committee.Briscoe, J. 1981. ‘Technical Aspects of Planning Water Supply Projects in Rural Areas’,

in National Council for International Health, Water Supply and Sanitation in Rural Development, pp. 77–85.

Choudhury, W.A., F.A. Quraishi, and Z. Haque. 2006. ‘Mental Health and Psycho-social Aspect of Disaster Preparedness in Bangladesh’, International Review of Psychiatry, 18(6): 599–605.

Collins, A.E. 2009. Disaster and Development. London: Routledge Perspectives in Development Series.

Collins, A.E. and M. Lucas. 2002. ‘O Que Aconteceu? ’ (What happened?), Report on Environmental Health Preparedness, Response and Lessons Learnt from Recent Flooding Emergency in Mozambique, Ministry of Health, Government of Mozambique.

Cuny, F.C. 1993. ‘Introduction to Disaster Management. Lesson 2: Concepts and Terms in Disaster Managment’, Prehospital and Disaster Medicine, 8(1): 89–94.


Dorosh, P., D.C. Ninno, and Q. Shahabuddin. 2004. The 1998 Floods and Beyond: Towards Comprehensive Food Security in Bangladesh. Dhaka: University Press Limited.

Edgeworth, R. and A.E. Collins. 2006. Self Care as a Response to Diarrhoea in Rural Bangladesh: Empowered Choice or Enforced Adoption?, Social Science and Medicine, 63(10): 2686–97.

Elahi, K.M. 2001. ‘Drought in Bangladesh: A Study of North–West Bangladesh’, in K. Nizamuddin (ed.), Disaster in Bangladesh: Selected Readings. Dhaka: Disaster Research Training and Management Centre.

Fewtrell, L., R. Kaufmann, D. Kay, W. Enanoria, L. Haller, and J. Colford. 2005. ‘Water, Sanitation and Hygiene Interventions to Reduce Diarrhoea in Less Developed Countries: A Systematic Review and Meta-analysis’, Lancet Infect Diseases, 5(1): 42–52.

Few, R. and Matthies. (eds). 2006. Flood Hazards and Health: Responding to Present and Future Risks. London: Earthscan.

ICDDRB. Archive. International Centre for Diarrhoeal Disease Research Bangladesh.IFRC. 1993. World Disasters Report, International Federation of Red Cross. Norwell,

MA: Kluwer Academic Publishers.Kunii, O., S. Nakamura, R. Abdur, and S. Wakai. 2002. ‘The Impact on Health

and Risk Factors of Diarrhoea Epidemic in the 1998 Bangladesh Floods’, Public Health, 116(2): 68–74.

Kafi luddin, A.K.M. 1991. Disaster Preparedness for Bangladesh: Floods and Other Natural Calamities. Dhaka: Md. Salauddin & Taslim Jahan Publisher.

Lechat, M.F. 1979. ‘Disasters and Public Health’. Bulletin of World HealthOrganization, 57(1): 11–17.

Lucas, M. and A.E. Collins. 2002. ‘O Que Aconteceu?’ (What Happened?), Report on Environmental Health Preparedness, Response and Lessons Learnt from Recent Flooding Emergency in Mozambique for Ministry of Health. Government of Mozambique.

Maskrey, A. 1989. Disaster Mitigation: A Community Based Approach. Oxford: Oxfam. Mitra and Associates. 1992. The 1991 National Survey on the Status of Rural Water

Supply and Sanitation. Dhaka: DPHE/UNICEF.MHFW. 1992. Proceedings of a Workshop on Lessons Learnt During Cylone – April 1991.

Ministry of Health and Family Welfare, Government of Bangladesh. Dhaka: Royal Printing Press.

Nahar, P., F. Alamgir, A. Bhuiya, A. Collins. 2010. ‘Contextualizing Disaster in Relation to Health in Bangladesh’, Asian Journal of Environment, Water and Pollution (Special issue on Water and Health), 7(1)( January): 55–62.

Noji,K.E. (eds). 1997. The Public Health Consequences of Natural Disaster. Oxford: Oxford University Press Ltd.

PAHO. 2000. Natural Disasters: Protecting the Public Health. Washington, D.C.: Pan American Health Organization.

Phillimore, P. and S. Moffatt. 1994. ‘Discounted Knowledge: Local Experience, Environmental Pollution and Health’, in J. Popay and G. Williams (eds). Researching the People’s Health, pp. 134–56. London: Routledge.


Rahman, A. 1989. Human Response to Natural Disasters: Issues Involved. Dhaka: Bangladesh Institute of Development Studies.

Rahman, A. and C.S. Ahmad. 1991. ‘Disaster and Development: A Study inInstitution Building’ Vol II, CEO Occasional Paper 3. Dhaka: United Nations Development Programme.

Rashid, S. and S. Michaud. 1999. ‘Female Adolescents and Cultural Notions of Honour, Shame, Purity and Pollution During Flood’, Experiences of Deluge: Flood 1998. Dhaka: Bangladesh Rural Advancement Committee Research and Evaluation Division.

Rice, C., H. Roberts, S.J. Smith, and C. Bryce. 1994. ‘It’s Like Teaching Your Child to Swim in a Pool Full of Alligators: Lay Voices and Professional Research on Child Accidents’, in J. Popay and G. Williams (eds). Researching the People’s Health, pp. 115–33. London: Routledge.

Siddique, A.K, A.H. Baqui, A. Eusor, K. Zaman. 1991. ‘1988 Floods in Bangladesh: Pattern of Illness and Causes of Death’, Journal of Diarrhoeal Disease Research, 9(4): 310–14.

Toole, M.J. and R.J. Waldman. 1993. ‘Refugees and Displaced Persons: War, Hunger and Public Health’, Journal of the American Medical Association, 270(5): 600–05.

UNDP. 1992. ‘Disaster Management – Basic Concept and defi nitions’, United Nations Development Programme Working paper 6. Dhaka: Ministry of Relief, Government of Bangladesh.

———. 2004. Reducing Disaster Risk, Bangladesh Report. Dhaka: United Nations Development Programme.

———. 2008. Development Report 2007/2008 – Fighting Climate Change: Human Solidarity in a Divided World. New York: United Nations DevelopmentProgramme.

UNICEF. 1987. Bangladesh Report. Dhaka: United Nations International Children’s Emergency Fund.

Woodruff, B.A., J.M. Toole, and D.C. Rodriguez. 1990. ‘Disease Surveillance and Control after a Flood in Khartoum, Sudan, 1988’. Disasters, 14: 151–63

WHO. 1980. World Health Report, WHO Chronicles. Geneva: World Health Organization.

———. 2004. WHO Report. Geneva: World Health Organization.Zaman, S. 1999. ‘Health During Disaster: Sharing Experiences with 1998 Flood

Victims’, Experiences of Deluge: Flood, 1998. Dhaka: BRAC Research and Evaluation Division.

19

Health Disasters

Tsunami-Induced Public Health Crisis in India

NIBANUPUDI HARI KRISHNA AND

PARNASRI RAY CHODHURY

INTRODUCTION

THE PUBLIC HEALTH consequences of a tsunami-like disaster was refl ected in the huge debris that lined the Indian coast for several months—damaged houses and latrines; submerged water sources; con-taminated tubewells, and destroyed natural vegetation. A large number of men and children were forced to defecate in the open grounds near the transit shelters, thus inviting the risk of vector diseases. Women were forced to defecate only in the dark, which forced them to eat and sleep at odd hours that eventually affected their health. Public health risk arises when a particular hazard interacts with compro-mised access to water-sanitation and behavioural practices, resulting in physical, social, economic and environmental vulnerabilities. Thus, public health promotion is the planned and systematic attempt to enable people to take action to prevent or mitigate disease. It com-bines intra-organisational knowledge with community perspectives. For example, (i) the causes of disease, epidemiology, vector control and communications and (ii) learning strategies. Hence, the public health promotion in emergencies can be used to target a wide variety of issues with specifi c focus on the control of water and vector-borne diseases, including prevention of diarrhoeal diseases and malaria in a post-disaster context.

426 Nibanupudi Hari Krishna and Parnasri Ray Chodhury

INCREASING FREQUENCY OF DISASTERS AND THEIR IMPACTS ON HUMANITARIAN AGENCIES

The United Nations declared the 1990s as the Decade of Natural Disaster Risk Reduction. A number of initiatives were undertaken globally by the state actors to reduce disaster risk. However, since 2000, disasters of much larger scale and with greater frequency have occurred. Scientists argue that rapid changes in the global cli-mate compounds the risk of natural disasters across the world, par-ticularly in South Asia, where hydro-meteorological hazards are more frequent and more intense.

According to the 2005 report of the World Conference on Dis-aster Reduction (WCDR 2005), the challenges posed by losses during disasters are on the rise, with grave consequences on the survival, dignity and livelihood of individuals, particularly the poor, and on hard-won development gains. Disaster risk is increasingly becominga global concern and its impact in one region can spiral risks in another. This, compounded by increasing vulnerabilities related to changing demographic, technological and socio-economic conditions, unplanned urbanisation, environmental degradation, competition for scarce resources and the impact of epidemics such as HIV/AIDS, points to a future where disasters could increasingly threaten world economies and its people.

Since 1990 more than 200 million people have been affected on an average every year by disasters (Oxfam 2005a). Over 700 disasters were reported worldwide in 2004 and 2005. If the 2004 tsunami took around 300,000 lives in south and Southeast Asian countries, over six million people were displaced in 2005 in Sudan, Congo and Uganda due to internal confl ict. Further, hurricane Katrina affected over 2.5 million people in USA, over 4 million people were affected bySouth Asia earthquake in the Kashmir region of India and Pakistan and over 10 million people face starvation in West Africa due to famine (Oxfam 2005b).

According to a 2008 report of the Environmental News Network (ENN), in the fi rst six months of 2008 alone 400 natural disasters took place in different parts of the world. Around 80 per cent of the disasters reported were caused by fl ash fl oods, hurricanes, tidal

Health Disasters 427

waves and thunderstorms. Cyclone Nargis, which hit Myanmar in May 2008 is estimated to have killed around 138,000 people, while the earthquake in south–west China’s Sichuan province in the same month left a death toll of 87,500. The same report informs thatmore than 230,000 people lost their lives from other natural disasters and another 130 million were affected in the fi rst six months of 2008, causing over US$ 50 billion in economic losses and US$ 13 billion in insured losses, compared with US$ 35 billion and US$ 9 billion, respectively, over the past decade (ENN 2008).

HUMANITARIAN AGENCIES AND DISASTER STRESS The increasing frequency of disasters has caused signifi cant stress on the capacity of global humanitarian agencies in terms of human and monetary resources. According to a Global Humanitarian Assistance (GHA) report 2006, around US$ 18 billion was raised for hum-anitarian assistance in 2005. Out of this, around US$ 6 billion was for tsunami-affected areas alone (GHAS 2006). The stress also shows in the availability of trained and capable human resources to serve in disaster affected areas. There are about 500,000 personnel serving across the world in different humanitarian situations in various cap-acities. Over half of them are reported to have been mobilised since 2005 (WDR 2008). However, the affected areas continue to witness shortage of trained human resources, particularly in specialised fi elds like public health engineering, water and sanitation engineering, habitation designing and management and hygiene promotion.

Public health response in humanitarian emergency situations includes a wide range of services related to water, sanitation, safe disposal of solid waste and excreta, vector control, shelter and pro-motion of hygiene. Water and sanitation, however, are the most crucial for preventing communicable diseases in the aftermath of a disaster. Provision of safe water in crisis situation has been the most diffi cult challenge for humanitarian workers. Several emergencies have shown that displaced people, out of desperation, resort to using unsafe water that results in serious health consequences for them.

The foremost task of humanitarian workers during emergencies is distribution of safe water, followed by improving the quality of water


at the nearest source to ensure safe supplies for a longer period of time. Although problems of stagnant water and excreta disposal may not appear critical for immediate survival, these eventually create perfect conditions for public health disasters. If adequate and safe sanitation facilities are not built into the habitation plan, the already stressed population becomes more vulnerable. However, such facilities can only be sustained with hygiene education and an effective drainage and waste disposal system.

About 60–95 per cent (Noji 1997) of reported deaths among disaster or confl ict affected refugees and displaced populations are due to malnutrition, diarrhoea, measles, acute respiratory infections and malaria. Humanitarian agencies consider all of these as outcomes of public health crises. Unfortunately, public health crisis is rarely recog-nised except when there is a signifi cant scale of dislocation among peo-ple in the aftermath of a natural disaster. It has been observed duringmany humanitarian responses that communicable diseases that were under control due to measures like vaccination, spraying, and so on, resurfaced as a result of disruption of public health infrastructure during disasters and large scale human confl icts. Water and sanitation environment play a crucial role in the transmission of disease-causing pathogens from person to person (WHO 2006).Water and sanitation related problems are higher during fl oods caused by tidal waves and torrential rains. This trend is noticeable also due to the fact that there is more documentation of water and sanitation issues during fl oods compared to other natural disasters.

The most commonly referred cases of public health crisis include the 75,000 cases of plasmodium falciparum malaria associated with hurricane Flora in Haiti in 1966. There was a marked increase in typhoid, gastroenteritis, measles, viral-hepatitis within six monthsafter the hurricane in Dominican Republic in 1979, and over 25,000 cases of paratyphoid fever were reported after the massive storm in Indonesia in 1992. In 1988, over 17,000 cases of diarrhoea were reported after fl oods hit parts of Bangladesh. Several types of infections and diseases like cholera were reported among Katrina evacuees in the USA (Watson and Connolly 2007). Table 19.1 captures some of the disasters that led to a surge in communicable diseases.


PUBLIC HEALTH RESPONSE DURING EMERGENCIES

International NGO Oxfam defi nes public health as ‘promotion of health and prevention of disease through the organised efforts of society’. A public health intervention aims to ensure coordination between various sectors such as food and nutrition, water and sani-tation, shelter, healthcare, and so on and to base its actions on sound public health information which is aimed at the maximum impact for the greatest number of people (Oxfam 2003).

In its 2007 report, the United Nations Children’s Fund (UNICEF) provided its fi eld workers with several guidelines:

Ensure the availability of safe drinking water. Provide bleach, chlorine or water purifi cation tablets, jerry cans or an appropriate alternative, including detailed instructions and messages in the local language on handling of water and disposal of excreta and solid waste. Provide soap and disseminate key hygiene messages on the dangers of cholera and other water- and excreta-related diseases. Facilitate safe excreta andsolid waste disposal by providing support for equipment, education/communication and operational costs. Always take into account the pri-vacy, dignity and security of women and girls (UNICEF 2007: 16).

According to Sphere’s humanitarian charter, ‘Water and sanitation are critical determinants for survival in the initial stages of a disaster’

Table 19.1: Incidence of Communicable Diseases Due to Floods

Year Location Communicable diseases198819901991199419981999199920002003200320042005

BangladeshWestern IndiaBangladeshWestern IndiaWest Bengal, IndiaBangladeshOrissa, IndiaMumbai, IndiaBangladeshNorthern IndiaMuzaffarabad, Pakistan

Diarrhoea Malaria Diarrhoeal diseases Malaria CholeraDiarrhoeal diseasesCholera and malariaLeptospirosisDiarrhoeal diseasesDiarrhoeal diseases and respiratory diseasesDiarrhoeal diseases, hepatitis ADiarrhoeal diseases, hepatitis E, hepatitis B

Source: WHO (2006).


(Sphere 2004: 56). Importance of safe water mobilisation to prevent public health crisis is further emphasised by United Nations High Commissioner for Refugees (UNHCR) in its 2004 report, stating, ‘the provision of water demands immediate attention from the start of a refugee emergency’. However, the report emphasises that ‘water quality is diffi cult to assess. Always assume that all water available during emergencies is contaminated, especially if it is taken from surface water bodies (lakes, ponds, rivers, and so on). All sources of water used by refugees must be separated from sanitation facilities and other sources of contamination’ (UNHCR 2004: 16).

Most humanitarian agencies believe that during emergencies it is important to monitor the impact of hygiene promotion, including the change in community hygiene practices which can signifi cantly contribute to the reduction of water sanitation and hygiene related diseases. Critical information provided by public health promotion in transit camps and temporary—intermediate settlements can feed into an effective emergency response plan and future evaluation since this helps to focus response objective where necessary. It is important that the people working in camps and temporary shelters are not just distributing emergency supplies and collecting damage data, but also obtain critical information with relevant data analysis, identifying the radical strengths or the weaknesses of the response programme and help in decision-making (Table 19.2, Map 19.1).

THE 2004 TSUNAMI AND ITS AFTERMATH

The World Bank assessment report of (March 2005) claimed loss of 10,000 human lives in India during the 2004 tsunami and overall economic losses to the tune of over US$ 1.5 billion. Besides the high toll, the serious injuries people received, the dislocation of families and loss of livelihood assets added to the distress of surviving families and individuals. Majority of those affected on the coast were fi sherfolk who suffered maximum damage, losing homes and productive assets like boats and nets. The impact of the Asian tsunami related to water environment can be described in three time frames (Table 19.3).

The tsunami also caused extensive environmental damage along the 2,260 km Indian coastline, resulting in erosion and accretion in

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numerous places as well as associated sedimentation of lagoons and waterways, causing extensive salinity of agricultural land and ground and surface freshwater resources. Post-tsunami, the seabed’s organic deposits surfaced on land, creating huge debris that damaged various fi sheries and aquaculture resources and coconut and other plantations.

The World Bank report mentioned compete collapse or serious damage to over 150,000 houses in the three affected states of India at an estimated loss of US$ 228.5 million. Health services in the three states were disrupted as their hospitals and even local medical centres

Map 19.1: Locations of Tsunami-hit Areas

Source: ESA (2005).

Table 19.3: Phase-wise Impact of Tsunami on Water Resources

Immediate Destruction of water sources and wastewater treatment plants, supply pipes and sewers.

Medium term Contamination of water supplies, appearance of salt and silt in the supply chain makes water unusable for consumption. Possible contaminations from biological sources (human and animal corpses, dead vegetation, and so on).

Long term Aquifer contamination by salt water


were seriously damaged estimating a loss of over US$ 16 million. Similarly, the loss to drinking water infrastructure in the states was to the tune of US$ 8 million and damage of drainage and sanitation infrastructure led to a loss of over US$ 4 million (World Bank 2005). In Sri Lanka over 12,000 wells were affected or permanently dam-aged by high salinity as a result of sea water ingress into aquifers after tsunami (ICMH 2005).

While the World Bank assessment looked into the infrastructural losses related to water and sanitation, scores of other reports by NGOs, technical experts and local institutions studied the invisible damage caused and its long-term impact. Once the communities moved in to the transit shelters, humanitarian agencies were confronted with the massive challenge of constructing environmentally-safe latrines, sourcing water for different needs, putting some sort of drainage sys-tems in place, waste management, hygiene education, ensuring pro-tection of women and addressing gender- and age-specifi c water, health and sanitation needs. In Tamil Nadu, Sri Lanka and Indonesia, many NGOs reported that the tsunami introduced many new sani-tation problems, especially among displaced people. Some of them had never had formal sanitary arrangements other than open ground and/or the sea. They found themselves in ‘camps’ where they had to be instructed on the proper use of latrines and its importance for public health (ICMH 2005).

In India, reports from all the states and Andaman Nicobar Islands affected by tsunami showed a high increase of salinity in aquifers along the coast. These shallow aquifers were further contaminated by closely located septic tanks and other sanitation facilities. During the relief phase, many NGOs installed hand pumps near latrines without marking that the hand pumps were not for drinking water. Another public health risk after tsunami was the huge debris that remained for several weeks in and around the crowded transit shelters. The debris kept piling up due to poor hygiene behaviour of the shelter inmates. Appropriate and timely debris removal could have sig-nifi cantly reduced the public health risks, especially in the Andaman and Nicobar Islands. The huge debris scattered over Nicobar group of islands including Car Nicobar, Kamorta, Trinket and Cambell Bay, especially along the broken jetties, resulted in the spread of several


water- and vector-borne diseases such as mMalaria and diarrhoea. Heavy rains, immediately after the tsunami, further affected the already inadequate relief work.

A report by Rajendran et al. (2006) says the most common health problems among the tsunami affected included traumatic wound infections and aspiration Pneumonia due to inhalation of soil con-taminated salt water. This report also reveals that over 35 per cent of the water sources that supplied water to the inhabitants of tsunami relief shelters in Kanniyakumari district of Tami Nadu were con-taminated and unsafe for human consumption. Further, many reports in the relief phase noted that toilets were not being used in a number of places, either due to their poor construction, lack of associated facilities or lack of community acceptance.

CHALLENGES FOR HUMANITARIAN AGENCIES

Providing minimum clean water for drinking, cooking and washing to each temporary camp site and intermediate settlements is a chal-lenge primarily because of groundwater contamination and damage caused to water storage infrastructure and distribution pipelines. Many humanitarian agencies leave damaged open wells and unrepaired hand pumps due to lack of technical skills and resources. Humanitarian contingency plans, NGO development activities and government welfare schemes seldom address these issues thereby creating a recipe for public health crisis after every small and major disaster.

Another major area of concern with humanitarian operations is ageneral lack of awareness and capacity to provide safe systems for disposal of human excreta. For instance, in Andaman and Nicobar Islands, temporary latrine cubicles constructed by many NGOs induced further risks since most of them were made too far to the safety and comfort of users, especially women, or too near to drinking water sources. Several such challenges notwithstanding, humanitarianagencies, together with local governments, were able to prevent a second wave of public health disaster after tsunami. It was particularly evident in the Indian state of Tamil Nadu, where the government was able to coordinate with humanitarian agencies and quickly deploy a


large cadre of health and sanitation workers soon after tsunami to minimise the consequences of debris and deluge on human health.

A comparative report of post-tsunami relief and rehabilitation services in India and Sri Lanka by Fritz Institute suggests that over 85 per cent of the affected population received drinking water within 48 hours of the disaster in India compared to only 70 per cent in Sri Lanka. Similarly, over 66 per cent of the affected population received medical services during this period in India and only 33 percent received such services in Sri Lanka. Of the 802 respondents interviewed by Fritz Institute in India, 15 per cent said that debris was removed from their locations within 48 hours, whereas only 8 per cent of the 600 respondents said so in Sri Lanka. It is important to note that over 85 per cent respondents of this study in India quoted local administration as the key service provider in the fi rst 48 hours, whereas only 4 per cent of the respondents in Sri Lanka named the government as the key service provider. Several studies suggest that UN agencies and international NGOs played a crucial role in com-bating and controlling the outbreak of an epidemic in tsunami-hit areas. The UN agencies alone supplied over 100,000 anti-malarial tablets in Sri Lanka. There were only 1,628 reported cases until one year after tsunami. The medical supplies remained stocked in all the districts in this malaria-prone country (Reliefweb 2005).

GOOD PRACTICES: CASE STUDY OF WATERSUPPLY AND HYGIENE PROMOTION IN

ANDAMAN AND NICOBAR ISLANDS

Brichgunj was one the model rebuilding sites visited by Prime Minister of India Dr Manmohan Singh in 2006. The shelter unit accommo-dated 578 families from different parts, languages and cultures of Andaman and Nicobar Islands. The district administration considered this unit as a model for the integrated health and livelihood approach adapted at the site by INGO Oxfam.

In Brichgunj, Oxfam promoted awareness among the affected families on direct–indirect benefi ts and impact of safe water handling, protected sanitation and camp-based solid waste management and


good hygiene practices and helped to connect with comprehensive vil-lage life. In addition, Oxfam also ensured functionality of neighbouring primary health centres and provided skill development training for the youth and women. Oxfam’s strategy of engaging a large number of aged and youth groups as ‘hygiene promotion ambassadors’ in the shelter camps bore positive results. With the help of Oxfam, these health ambassadors mobilised and maintained 207,800 litres of water storage capacity to meet the needs of the residents. The volunteers also installed roof top rainwater harvesting structures to supplement the constrained water supply and also harvest the immense rainfall experienced by the area. Regular supply of chlorine tablets in the local dispensary was ensured for maintaining quality water supply. Further, trained public health workers also developed radio skits and messages on hygiene awareness which were broadcast by All India Radio in the Islands.

CONCLUSION

After every major disaster, there are different stakeholders making anxious attempts to improve the situation. Most of them come with a direct responsibility and facilitate the early response and recovery while others monitor and play the role of observers. However, as it is often the case, those who have a direct responsibility in early response and recovery do not get enough time to communicate adequately and identify defi nitely with the communities about their genuine needs, while those who have minimum function in such hardware support, play a major role in monitoring and providing the back-up support of social and moral counselling. Therefore, in such major emergencies, it is extremely essential for the stakeholders to establish or reinforce a common platform and ensure effective and timely exchange of critical information.

After tsunami, the local media, health professionals and relief workers often stated that the dead bodies could cause ‘epidemic and plague’. This fear forced local government authorities, aid agencies and community volunteers to quickly dispose off bodies. However, this was done in acute emergency mode with unprecedented rush and


sometimes without following the fundamental norms and ethics of ‘disposal of dead bodies’. This contributed to the overall contamination of existing surface water and sanitation facilities in the tsunami affected areas where the affected communities were eventually rehabilitated.

Providing clean water for drinking, cooking and washing to each temporary camp site and intermediate settlements was a huge chal-lenge, as groundwater had contaminated water storage infrastructure and distribution pipelines were damaged. Apart from being a publichealth hazard, this also caused high mental distress among thesurvivors’ relatives for not being able to mourn their dead except from creating legal problems where there were property, inheritance or insurance claims. If the emergency responses take care of these basic public health and mental health issues, the risk of post disaster epidemic can be minimised to a great extent.

THE WAY FORWARD

Globally there has been an increasing awareness on the need for disaster preparedness. Scores of models are available that demonstrate the innovative and appropriate ways of community level disaster risk reduction. The Hyogo Framework of Action (HFA 2005)1 has also been able to move several national governments to initiate policy measures to strengthen disaster risk reduction in their countries. These efforts have been going on with different levels of effi ciency and impact. Key to disaster risk reduction at the community or at the national level is the comprehensive assessment of disaster risk and vulnerability. This assessment should not limit just to the source of the hazard (risk) and potential subject of disaster (vulnerability). This assessment becomes more useful and effective when experts con-sider a thorough assessment of communicable diseases in the region, systems of surveillance and plans for hygiene awareness, immunisa-tion and vector-control campaigns.

1 Hyogo Framework of Action (HFA) is an action plan agreed upon by over 160 nations with the aim of building the resilience of nations and communities to disasters. The framework provides a strategic and systematic approach to reducing vulnerabilities and risks to hazards.


Community level disaster preparedness of several NGOs worldwide should make disease surveillance as part of the overall early warning strategies, design individual training module on the post-disaster risk management portfolio. Surveillance is key to understanding the impact of disasters on communicable diseases and death. It is also important to collect and safely store the baseline information that documents the disease profi le of the region. Absence of such information can cause delay in noticing the epidemic, initiating quick treatment and arrestingits spread in the aftermath of disasters. Similarly, early warnings in health risks may provide suffi cient time to prepare the community for related health risks especially when evacuation is not possible. For example, in India, tsunami caused widespread damage and added risks as residents were not warned in time. In contrast, in countries like Cuba and Puerto Rico, where hurricanes occur regularly, people experience relatively limited damage and loss of life because relief preparations are made even before the storm hits the areas.

Maintaining personal hygiene is always a challenge, especially when individuals lose access to basic public health facilities and continue to live in crowded temporary accommodation. It is often believed that public health casualties from natural disasters are unavoidable, but there are many measures that can reduce morbidity and mortality through hygiene promotion messages highlighting the importance of hand-washing and providing hygiene kits.

Community-led public health preparedness and risk reduction model that integrates public health awareness could save several thousands of lives. In the region of the Americas, Pan-American Health Organisation has spent many years promoting and integratingdisaster preparedness into building health facilities to ensure that medical services needed to treat victims and to maintain ongoing care for patients with chronic conditions are not disrupted by disasters. In addition to infrastructure and early-warning systems, another key element is education and raising awareness, using cost-effective mass media and developing public health risks and response plans. Greater awareness about the risk of tsunami perhaps could have saved many lives in 2004.


Several recent studies on health risks in fl ood-prone areas highlight the importance of disaster risk reduction and related preparedness within the health system. There should be an improvement in the qualitative and quantitative tools available currently for public health needs assessment in emergencies. For this, one needs to introduce simple, effective and user-friendly tools for public health needs assess-ment in emergencies. Also, adaptability and availability of essential public health knowledge amongst the fi eld-based public health vol-unteers must be ensured to make effective assessment of public health needs and the ground reality. Constant advocacy with the donors and international aid implementing agencies for reinforcing Community Based Disaster Risk Reduction, and developing community-based public health task force cadres is needed. Also regular training should be ensured for them with specifi ed modules and standard operation practice. Unless this is mainstreamed and made inclusive to com-munity contingency planning, only emergency-driven public health promotion will not be adequate to address, resolve and reduce its related health risks.

Further, structured coordination mechanism and making fundingproportionate to Unifi ed Public Health Response Strategies of inter-national humanitarian agencies focusing on ensuring access to pri-mary care is critical. Diagnosis and treatment of a wide range of diseases besides cholera and malaria is necessary. Debate and advocacy on the accreditation of agencies is necessary. Only well-qualifi ed and experi-enced agencies can respond to the specifi c public health needs during disasters. This campaign should combine with mass immunisation against a wide range of potential diseases and inclusion of vitamin supplementation in disaster prone areas with limited public health infrastructure.

REFERENCES

ENN. 2008. ‘Natural Disasters Becoming More Frequent’, 14 July. Environ-mental News Network. Available online at http://www.enn.com/climate/article/37640.

ESA. 2005. ‘A Year on from the Asian Tsunami, Satellites are Aiding Regional Rebuilding. 23 December. Available online at http://www.esa.int/esaEO/SEMF2J8A9HE_index_0.html. Downloaded on 29 June 2011.


Fritz Institute. 2005. ‘Lessons from the Tsunami: Top Line Findings’. Available online at http://reliefweb.int/sites/reliefweb.int/files/resources/4597711F44ECE9008525708A006C5BA3-Lessons%20from%20the%20Tsunami-Fritz.pdf. Downloaded on 29 June 2011.

GHAS. 2006. ‘Global Humanitarian Assistance Indicators, 2006’. Available online at www.globalhumanitarianassistance.org. Downloaded on 29 June 2011.

HFA. 2005. ‘Building the Resilience of Nations and Communities to Disasters’, Hyogo Framework for Action. Available online at http://www.unisdr.org/we/coordinate/hfa. Downloaded on 29 June 2011.

ICMH. 2005. ‘Interim Report of a Meeting on Public Health Impacts of Tsunami’, International Center for Migration and Health, Male, Republic of Maldives, 22–24 April.

Noji, E.K. (ed.). 1997. The Public Health Consequences of Disasters. Oxford: Oxford University Press, UK.

Oxfam. 2003. ‘Guidelines for Public Health Promotion in Emergencies’, 111: 9. UK: Oxford. Available online at http://disastermanagementbangladesh.org/oxfam_tools/Humanitarian%20publication/Emergency%20public%20health/Oxfam%20PH%20Promotion%20Guidelines.pdf.

———. 2005a. ‘Oxfam’s Tsunami Response Programme in Andaman and Nicobar Islands’, Annual Report, December.

———. 2005b. ‘Year of Disasters: Oxfam Briefi ng Paper’. UK: Oxford.Rajendran, P., S. Murugan, S. Raju, T. Sundararaj, B.M. Kanthesh, and E.V. Reddy.

2006. ‘Bacteriological Analysis of Water Samples from Tsunami-hit Coastal Areas of Kanyakumari District, Tamilnadu’, Indian Journal of Medical Microbiology, 24(2): 114–16.

Relief Web. 2005. ‘Sri Lanka: Facts Regarding Post-tsunami Recovery Six Months on’. Available online at http://www.reliefweb.int/rw/rwb.nsf/db900SID/KHII-6DY5LD. Downloaded on 24 February 2009.

Sphere. 2004. ‘Minimum Standards in Water Supply, Sanitation and Hygiene Promotion’, in Sphere Humanitarian Charter and Minimum Standards. Geneva: The Sphere Project.

UNHCR. 2004. Handbook for Emergencies, 2nd edn. United Nations High Com-missioner for Refugees. Available online at http://www.unhcr.org/publ/PUBL/3bb2fa26b.pdf.

UNICEF. 2007. Unicef Response in Emergencies: A Vademecum for Field Workers. The Offi ce of Emergency Programmes (EMOPS). New York: UNICEF.

Watson, J.T., M. Gayer, M.A. Connolly. 2007. Epidemics after Natural Disasters: Emerge Infect (serial on the Internet). Available online at http://www.cdc.gov/ncidod/EID/13/1/1.htm. Downloaded on 24 February 2009.

WCDR. 2005. ‘Report of the World Conference on Disaster Reduction, Kobe, Hyogo, Japan’. Available online at http://www.unisdr.org/2005/wcdr/intergover/offi cial-doc/L-docs/Final-report-conference.pdf.


WDR. 2008. World Disaster Report, 2008. Geneva: International Federation of Red Cross and Red Crescent Societies. Available online at http://www.ifrc.org/Global/Publications/disasters/WDR/wdr2008-full.pdf.

WHO. 2006. Communicable Diseases Following Natural Disasters: Risk Assessment and Priority Interventions. Geneva: World Health Organization. Available online at http://www.who.int/diseasecontrol_emergencies/guidelines/CD_Disasters_26_06.pdf.

World Bank. 2005. India Post Tsunami Recovery Program: Preliminary Damage and Needs Assessment. New Delhi: Asian Development Bank, United Nations and World Bank. Available online at http://www.adb.org/Documents/Reports/Tsunami/india-assessment-full-report.pdf.

Glossary

Annual Parasite Incidence: The total number of positive slides for the malaria parasite in a year multiplied by 1,000/total population. Hence it refl ects the confi rmed cases of malaria during one year in a population under surveillance and is based on both active andpassive surveillance; it is a robust indicator of malaria incidence in the community.

Attributable Fraction: Multiplier uses to calculate the proportion of the total disease burden that is directly linked to incomplete water and sanitation provisions.

Bir Dhara: Stand post for water supply constructed by formerNepalese prime minister Bir Shumsher Rana

Black-water: Waste discharged from the human body through toilets and urinals.

Case fatality rate: Proportion of reported cases which end in death.

Cost-benefi t analysis: A basic tool of economic analysis in which the actual and potential private and social costs of various economic decisions are weighed against private and social benefi ts.

Dhunge Dhara: Stone spout which gets water either from a spring or from groundwater and channels through artistically carved stone conduits.

Diarrhoea: As per Orissa Multi-Disease Surveillance System manual, simple diarrhoea is defi ned as acute diarrhoea (passage of three or more watery stools over a period of 24 hours) without dehydration. Severe diarrhoea is defi ned as acute diarrhoea with dehydration, with or without vomitting.

Disability-adjusted Life Years: A time-based measure that combine years of life lost due to premature mortality and years of life lost due to

Glossary 443

time lived in states of less than full health to present the full estimate of the burden of disease associated with a factor, in this case incomplete water and sanitation coverage.

Domestic wastewater: Wastewater originating from household and personal activities including toilets, baths, showers, sinks, kitchens and non-commercial laundries. This includes such wastewater from homes, schools, shops, offi ces, hotels and so on, while specifi cally excluding wastes from industrial processes.

Estate Community: A residential community living in plantation crop (tea, rubber or coconut) growing property or holding that may include more than one garden under the same management or ownership.

Externality: Any benefi t or cost borne by an individual that is a direct consequence of another’s behavior and for which there is no compensation.

Grey-water: Domestic wastewater from baths, showers, washbasins, kitchens and so on, other than black-water.

Groundwater table: The level below the ground surface at which groundwater is fi rst encountered during excavation.

Hiti: Water tap.

Labor productivity: The level of output per unit of labor input, usu-ally measured as output per worker-hour or worker-year.

Latrine pit: Pit of a latrine for accumulation and decomposition of excreta and from which liquid infi ltrates into the surrounding soil.

Maha Season: Greater monsoon, the main growing season under rain-fed conditions for paddy (rice) and most other annual crops. Sowing is between August and October, depending on the time of the monsoon, and the crop is harvested fi ve to six months later.

Mahadev Khola: Mahadev River.

Pani Goswara: Water Management Offi ce.

444 Interlacing Water and Human Health

Peri-urban agriculture: Farm units close to town which operate intensive semi-commercial or fully commercial farms to grow veg-etables and other horticulture and livestock.

Raj kulo: Iirrigation channels constructed by the State.

Sanitation: The science of maintaining a healthful, disease- and hazard-free environment.

Septic tank: A single or multiple-chambered tank in which wastewater is retained suffi ciently long to permit separation of solid particles and partial digestion of accumulated solids.

Sewage: Any wastewater, including all faecal matter, urine, household and commercial wastewater that contains human waste.

Soakage pit: A pit from which septic tank effl uent is allowed to seep into the surrounding soil.

Urban agriculture: Small areas such as vacant plots, gardens, verges, balconies and containers within the city for growing crops andraising small livestock or milk cows for own-consumption or sale in neighbourhood markets.

Wastewater: The spent or used water of domestic or commercial origin which contains dissolved and suspended matter.

Wastewater Treatment: Process of removing contaminants from industrial wastewater and household sewage.

Yala Season: Considered as the lesser monsoon, the secondary growing season for paddy (rice). Most other annual crops are grown between April and May and harvested four or fi ve months later.

About Editors and Contributors

EDITORS

Anjal Prakash is Senior Fellow at SaciWATERs, handling research and outreach portfolio under the Crossing Boundaries Project and Director of Project – Peri-urban water security in south Asia’.A graduate from Tata Institute of Social Sciences, Mumbai, India, Dr Prakash has a Ph.D. in Environmental Science from Wageningen University and Research Center, The Netherlands. He has worked extensively on issues of groundwater management, gender, natural resource management and water supply and sanitation in India. Before joining SaciWATERs, Dr Prakash worked with the policy team of Water Aid India, based in New Delhi, handling research and implementation projects related to Integrated Water Resources Management. He has contributed many papers in leading journals and chapters in several books. He has authored The Dark Zone: Groundwater Irrigation, Politics and Social Power in North Gujarat published by Orient Longman.

Saravanan V.S. is at the Center for Development Research, Univer-sity of Bonn, Germany. He specialises in understanding the linkages between urbanisation/globalisation, agriculture and human health in the fast growing economies of developing countries through the sec-tor of water resources management. He has interdisciplinary quali-fi cations from prestigious universities in India, United Kingdom and Australia. He draws on theories of integrated water resources management, new institutionalism in social science (rational-choice, organisational, historical and natural resource institutionalism) and systems approach to analyse risk from global environmental change on water resources and its implications on human health. His favourite topics for research include analysing power dynamics, policy processes, and spatial scales for water management, which he draws from his research experiences in South and Central Asia.


Jayati Chourey is a Senior Fellow (Education and Networking) with SaciWATERs. She is responsible for coordinating the SaciWATERs–CapNet Network (SCaN). She holds a Ph.D. in Ecosystem-based Water Resources Management from the Indian Institute of Forest Man-agement, Bhopal (Forest Research Institute University, Dehradun). The focus areas of her activities are water, ecosystems, health andlivelihoods. She has been an Environment Equity and Justice Partner-ship (EEJP) Fellow supported by Ford Foundation during 2005–06. She has worked with ENVID Group, Andhra University for Ecological and Economics Research Network (EERN) coordinated by Indian Institute of Science (IISc), Bangalore. She is associated with various environmental and social development forums.

CONTRIBUTORS

Amita Shah is Director of Gujarat Institute of Development Research. She is an economist with wide-ranging experience of researching on various aspects of rural economy. Her major areas of interests include dry land agriculture and forestry, environmental impact assessment, gender and environment, agriculture–industry interface, small scale and rural industries, employment–livelihood issues and chronic pov-erty. More recently she has been involved in a number of studies pertaining to participatory watershed development and integrated water resources management, protected area management, economic valuation of bio-diversity, chronic poverty in remote rural areas, migration and status of women in agriculture. She has undertaken a number of evaluation and impact assessment studies, especially for the projects related to natural resource management in various states such as Gujarat, Madhya Pradesh, Uttaranchal, Orissa and Karnataka. Over the past 20 years she has worked closely with a number of government and non-government organisations and participated in an informed process of policy formulation. She has also been a consultant to vari-ous donor agencies and has undertaken collaborative research both within and outside India. She has a Ph.D. degree in Economics and has published extensively in professional journals as well as books. She has been invited as visiting scholar to academic institutions in United Kingdom, China, France, Netherlands and Canada.

About Editors and Contributors 447

Abbas Bhuiya is Senior Social Scientist at the International Centre for Diarrhoeal Disease Research, Bangladesh. A Ph.D. holder in Demography, he has published over 100 articles.

Annette Fitzpatrick is a Research Associate Professor of Epidemiologyand Global Health at the University of Washington, School of Public Health, Seattle, Washington, D.C., USA. She holds a Ph.D. in Epi-demiology and a Master’s degree in Ecology. Along with her work on risk factors for chronic diseases in developing and developed countries, she has great interest in issues of infectious diseases related to poor water quality and lack of sanitation. In addition to working with the Living Earth Institute, she has performed health evaluations for Save the Rain, an NGO in California and has worked with Engineers without Borders to develop standardised measures for evaluation of projects. She currently directs studies of cardiovascular diseases in Vietnam, Chile and Nepal. She teaches graduate-level courses on epi-demiologic methods and research operations to students in the Schools of Medicine, Nursing, Pharmacology and Public Health at the Uni-versity of Washington. Dr Fitzpatrick has presented or co-presented at over 100 conferences and is or has been Principal Investigator of11 grants or projects primarily funded by the US National Institutes of Health. She has published over 80 articles in peer-reviewed national and international health journals.

Abedullah is Assistant Professor in the Department of Environmental and Resource Economics, University of Agriculture, Faisalabad (UAF), Pakistan. He has done his Masters and doctorate degrees in Agricul-tural Economics, specialising in Marketing and Resource Economics, respectively from the University of Philippines at Los Baños. He did his research in International Rice Research Institute (IRRI), Philippines. After completing his Ph.D. he has served in IRRI, Asian Vegetable Research and Development Centre (AVRDC), International Water Management Institute (IWMI) and University of Rostock, Germany. His research work includes effi ciency (technical, allocative, economic and environmental), quantifi cation of risk (production, marketing and management), economic benefi ts of enhanced agricultural pro-duction and consumption in Asia, and impact of wheat price policies on welfare distribution of different stake holders in Pakistan. He has


10 years of research and teaching experience in national and inter-national organisations. Currently he is working on a project funded by Punjab Agricultural Research Board (PARB), Punjab, Pakistan. He has 25 papers in national and international journals, 10 seminar papers or book chapters and nine newspaper articles to his credit.

Aidan Cronin has been managing the UNICEF water and sanitation programme in Orissa, India, since 2008. He trained as a civil and environmental engineer and holds a Ph.D. in water resources from Queens University, Belfast. His experience is principally in Water and Health and has published extensively in these areas. Prior to his work in India he was a Water and Sanitation Advisor at the United Nations High Commission for Refugees in their Public Health Sec-tion in Geneva, Switzerland. He has also worked as a Senior Research Fellow at the Robens Centre for Public and Environmental Health, University of Surrey, UK which is the WHO Collaborating Centre for the Protection of Water Quality and Human Health, where he spent fi ve years looking at the impact of anthropogenic activities on water quality in the EU and developing country settings.

Aravinda Satyavada is a visiting Fellow with the Institute of Human Development. She earned her doctoral degree from Kansas State University (KSU) in August 2004. Her areas of specialisation and research interests include social demography, gender, fertility and family planning, reproductive health and child nutrition. She is a 1998–99 Policy Communications Fellow, Population Reference Bureau, Washington, D.C.

Archana Chowdhury (MD) is currently working towards improvingchild survival in the states of Rajasthan, Uttar Pradesh, Madhya Pradesh, Bihar and Orissa under NIPI (Norway–India Partnership Initiative). She specialised in Community Medicine after completing her MBBS and joined the development sector in 2004. She has con-siderable experience in Public Health, especially Maternal and Child Health. She has developed, managed and administered comprehen-sive programmes in the health sector and provided implementation support, strategy formulation and process design of preventive and


promotive health interventions for rural communities in Haryana with focus on NRHM, RCH and water and sanitation programmes.

Biraj Swain is currently associated with the global development knowledge partner and consulting fi rm Infrastructure Professionals Enterprise. She is also engaged as Advisor with DFID supporting the Madhya Pradesh Health Sector Reforms Programme, and Orissa Development Policy Support Programme. She is also involved with the Multi-Donor Trust Funded ‘Protection of Basic Services’ initiative in Ethiopia. She is a development and governance expert specialsing in sectors like water and sanitation, electricity, health, public transport and nutrition. Her work focuses on democratising governance of regulatory mechanisms of essential services and designing inclusive and equitable systems responsive to citizens’ engagement. Her expertise is in understanding and designing delivery models in health, water sanitation, energy and their respective regulatory regimes from the equity and governance perspective. She has been a supporter and analyst of social movements, civil liberties and economic, social and cultural rights and State response. She has worked with ADB, World Bank – WSP and HNP, DFID, USAid, CARE, WaterAid and ActionAid in India, South Asia and East Africa. She is an active member of Centre for Budget and Governance Accountability and teaches courses at the Pondicherry Central University and United Nations University, Japan.

Dibya Ratna Kansakar was Executive Director at SaciWATERs during 2008–10. He was also the Director of Crossing BoundariesProject during that period. He holds a Ph.D. in Geology from the M.S. University of Baroda, India. He was working as the Chief Hydro-geologist in the Department of Irrigation, Government of Nepal before he joined SaciWATERs in 2008. He had contributed in vari-ous capacities in different aspects of water resource development and management, particularly groundwater resources in Nepal, including the formulation of National Water Resources Strategy and in the implementation of Community Groundwater Irrigation Sector Project as its Director. He has been a Hubert H. Humphrey Fellow at the University of Washington, USA, and also a visiting scientist at the


University of Hawaii and an Adjunct Research Associate at East West Center, Hawaii, USA. He is the founding Chairman, Nepal National Committee, International Association of Hydro-geologists. He has contributed numerous scientifi c research papers in leading national and international journals, and chapters in books. His current areas of interest are interdisciplinary water resources management, water policy and water and equity.

Fariba Alamgir is a Senior Research Offi cer at the Social and Be-havioural Sciences Unit at ICDDR, Dhaka, Bangladesh. She has done her bachelors and masters in Anthropology from the University of Dhaka, Bangladesh. Presently she is pursuing her second masters in Development Studies from the Institute of social Studies at The Hague in Netherlands. She co-authored a paper titled ‘Climate Change and Food Security: Health Risks and Vulnerabilities of the Poor inBangladesh’, published in the International Journal of Climate Change.

Faisal Abbas is Junior Researcher at the Department of Economic and Technological Change, Center for Development Research (ZEF), University of Bonn, Germany. Currently, he is a Ph.D. candidate researching on Health Economics issues related to developing count-ries focusing on Pakistan. He has completed his MSc in Agricultural Economics and wrote his thesis on rural poverty issues. He has been a Researcher for a DFID-funded project related to urban health issues in Faisalabad, Pakistan. Faisal Abbas was awarded the German Academic Exchange Service (DAAD) research scholarship relevant to developing countries for pursuing his Ph.D. He was a Carlo Schmidt Fellow (Intern) at World Health Organization, Geneva, Switzerland in 2009. His work has been accepted in conferences like Macroeconometric Workshop at the German Economic Institute (DIW) at Berlin, and the 2008 Berkeley Conference on the Global Health Workforce: From Evidence and Research to Public and Health Care Industry Policy at University of Berkeley at California, USA and European Conference in Health Economics, Rome (ECHE–ROMA). He has written on issues related to rural poverty, micro-credit, education and health economics in reputed journals. Also, he has published in popular


press on economic development of Pakistan. He is also selected as ‘Our Common Future Fellow’ by Volkswagen (VW) Foundation, Germany.

I.H. Rajapakshe is Water, Sanitation and Hygiene Advisor at HelpAge, Sri Lanka. She has earned her B.Sc. Special Degree in Agriculture with a Second Class pass in 2006 from the Faculty of Agriculture, University of Peradeniya, Peradeniya, Sri Lanka. She received a SAWA Fellowship awarded by the Crossing Boundaries Project to pursue her M.Phil. degree in Integrated Water Resources Managementfrom Post-graduate Institute of Agriculture, University of Peradeniya, Sri Lanka in 2009,. She has published three articles in peer reviewed journals and a presented a paper in a conference.

Jason Soh works at the University of Washington International AIDS Research and Training Programme and does research among HIV-1 discordant couples in Kenya. He is a Masters student of Public Health programme in the Department of Epidemiology at the University of Washington, Seattle, WA, USA. While completing his Bachelor’s degree in Microbiology at the University of Washington, he par-ticipated in a research project in the Republic of Georgia with the University of Washington Multidisciplinary International Research Training (MIRT) Programme. He met Dr Annette Fitzpatrick through the MIRT Programme and continued collaborating withher on this project assessing the health impact of community develop-ment in Nepal. He received the Mary Gates Research Scholarship for his undergraduate research efforts. After graduating, he volunteered in China and South Korea before beginning his graduate studies. He is interested in studying infectious diseases in low-resource settings.

Kamla Gupta is Professor and Head of the Department of Migra-tion and Urban Studies at the International Institute for Population Sciences (IIPS), Mumbai. She is also the Chief Coordinator of theNational Family Health Survey (NFHS-3, 2005–06), third in the NFHS series of surveys. She holds a Ph.D. in Geography with spe-cialisation in Population Geography.. Her areas of specialization include migration, urbanisation, environment, gender and health.


She has contributed immensely in these areas, having more than twenty national and international publications to her credit. She has guided several students for M.Phil. dissertation. Six students have completed, and three students are currently pursuing, their Ph.D. under her guidance. She has visited countries like USA, Switzerland, Austria, South Korea, Canada and Singapore for disseminating her work.

Kevin Fitzpatrick is the Manager of the Water Quality Section at the Washington Department of Ecology’s Northwest Regional Offi ce carrying out the mission to protect and preserve the waters of Washington State (USA). Overseeing 44 professional staff including environmental engineers, hydrologists and environmental scientists, the projects have included developing permits for airport runways, a new light rail train system in the region, the Seattle Monorail and King County’s new sewage treatment plant. Kevin received a Bachelor of Science in Biology from Loyola University and a Master of Arts in Zoology from Southern Illinois University. He was an Offi cer in the United States Coast Guard working in pollution control and vessel inspection prior to his retirement from the Reserves as a Lieutenant Commander. He has been with Ecology for over 24 years and has held positions as the chief criminal investigator, water quality inspector, and unit supervisor for the Industrial Permit Unit prior to his role as Manager of the Section.

Lalit Mohan Sharma is Group Leader (Programme Implementation Centre) and Water Management, Institute of Rural Research and Development (IRRAD), an initiative of Sehgal Foundation. He is a civil engineer and holds a Master of Technology (Management and Systems) degree from the Indian Institute of Technology, Delhi. Under his leadership IRRAD’s water management programme has achieved wide recognition. The organisation has won UNESCO–Water Digest ‘Best Water NGO’ award for ‘Revival of Rural Water Resources’ in 2009 and 2010 and ‘Best Water NGO’ for ‘Rain Water Harvesting’ in 2008. He is a member of the Technical Expert Com-mittee on ‘WAR for Water’ initiated by the Department of Science and Technology under the direction of the Supreme Court of India


to fi nd out research-based technological solution for water problems. He has presented papers on issues related to integrated and sustainable development of water resources.

Leela Iyengar is working as a consultant for Argyam, Bangalore. Some specifi c studies include the evaluation of cystine-amended H2S strip test for assessing the bacteriological quality of water, defl uoridation of drinking water, water quality monitoring in Kanpur and Ballia dis-tricts. She was Chief Scientifi c Offi cer in the Department of Chemistry at the Indian Institute of Technology (IIT), Kanpur, and worked in the area of water quality monitoring and wastewater treatment till she retired in 2007. She was a member of the task force committee for arsenic, Uttar Pradesh, till her retirement. She has also participated in various training programmes on Fluorosis and its mitigation in various parts of India. She contributed a chapter on ‘Technologies for Fluoride removal’ for the book Small Community Water Supplies: Technology, People and Partnership edited by Jo Smet and Christine van Wijk, published by IRC International Water and Sanitation Centre, Delft, The Netherlands (2002). She has published several papers in peer reviewed national and international journals.

M.M.M. Najim is a senior lecturer in Environmental Conservation and Management and is attached to the Faculty of Science, University of Kelaniya, Kelaniya, Sri Lanka. He completed B.Sc. Agric. Hon. with a First Class in 1994 from the University of Peradeniya, Sri Lanka. He has earned his M.Eng. in Irrigation Engineering and Manage-ment from the Asian Institute of Technology, Thailand in 2000 and his Ph.D. in Water Resources Engineering from University Putra Malaysia, Malaysia in 2004. Dr Najim’s major research interests are environmental issues related to water and soil pollution, agricultural water management, wastewater irrigation and sanitation and health issues. He has served as consultant to many local projects mainly in the water sector. He has published over 40 research papers including 23 in refereed journals and 11 in conference proceedings. He has contributed two chapters in books and has translated a monograph. Dr Najim is a life member of many professional societies and holds key positions in those societies.


Meera Kansakar is an economist and has post-graduate training in Population Economics from the University of Hawaii, Honolulu. She worked as Assistant Population Expert for 17 years with National Population Commission, Population Division, and Child and Women Development Section of National Planning Commission and later in Ministry of Population and Environment of Government of Nepal. Since 1997, she is a Founder Member of Institute for Managing Pro-ductive Research and Studies (IMPRESS) Pvt. Ltd, a private research institute registered under company act 1965 in Nepal. She has also been actively involved in community water supply, sanitation and women development projects in rural Nepal since 2001. Her areas of interest are demography, population and development, women and development, social statistics, project monitoring and evaluation, and women empowerment through community development. She is a life member of Population Association of Nepal (PAN) and National Health Economics Association (NHEA).

Nalini Sankararamakrishnan is a Research Scientist in Centre for Environmental Sciences and Engineering at IIT Kanpur. She received her Ph.D. from the Indian Institute of Technology (IIT), Chennai, India, in 1997. After a short span as visiting scientist in University of Illinois, Urbana Champaign, she joined Rutgers University, New Jersey as Post-doctoral Research fellow in the Department of Civil and Environmental Engineering. She then worked at IIT Kanpur as Senior Project Scientist. Her research interests include evaluation of fi eld kits, mechanism of mobilisation of arsenic, eco-friendly approach for industrial effl uent treatment, defl uoridation and decontamination of arsenic from ground water. Currently her group has developed a novel biopolymer for the decontamination of arsenic from arsenic-contaminated drinking water. Recently in a UNICEF sponsored project, defl uoridation fi lter units have been successfully deployed and evaluated in a few fl uoride affected schools of Rajasthan. She has published several papers in peer reviewed international journals. She is an active member of Arsenic Task Force, Uttar Pradesh, India.

Nibanupudi Hari Krishna had his formal education in Communica-tion and Business Management. He has also been trained in Envir-onment Education, Natural Resource Management, Humanitarian


Assistance and Humanitarian Law. He has 12 years’ experience on these subjects, with special focus on promoting a Culture Disaster Risk Reduction. He worked with Oxfam UK from 2001 to 2005 as Humanitarian Programme Manager in South India and with Oxfam America from 2005 till 2009 as India Humanitarian Representative.During this period he commissioned and coordinated over 30 humanitarian research projects and published over a dozen books, training manuals and videos which contributed to global humanitarianlearning. He earlier worked with Indian Institute of Management and Institute of Rural Management, Anand. Hari Krishna has been associated with World Bank Institute’s online courses on disaster management as resource person since 2004. He provided evaluation and impact assessment consultancy support to Welt Hunger Hilfe, UNICEF and CARE India. He has also been visiting faculty at various academic and training institutions in India on disaster management. He delivered talks at School of Public Health, Harvard University and Council on Foundations in the USA on policy and practice issues of disaster risk reduction in the aftermath of Tsunami.

Mohua Guha is Programme Manager in the offi ce of the Dean, Research and Development, Tata Institute of Social Sciences (TISS), Mumbai. She is a Ph.D. Scholar at the International Institute for Population Sciences (IIPS), Mumbai working on ‘Arsenic Pollution and its Consequences: A Case Study of West Bengal’. She has com-pleted her M.Phil. in Population Studies from IIPS and was awarded the C. Chandrasekharan Gold Medal. She also holds an M.Sc. in Geography from University of Calcutta and MA in Sustainable De-velopment from Staffordshire University, UK. Her areas of interest include community and public health, environment, and urban studies. She has presented her research papers at several national and inter-national conferences, and has visited countries like France, Kenya, Morocco, China, USA, and Switzerland. She has to her credit more than 15 national and international publications in peer-reviewed journals and edited books. She has worked as a Research Associate in an IDRC consultative work ‘Health Research and Policy: Mapping South Asia’ spanning across the fi ve countries of Bangladesh, India, Nepal, Pakistan and Sri Lanka.


Nibedita S. Ray-Bennett teaches in the Department of Sociology at Warwick University. She has MA in Social Work from Tata Institute of Social Sciences, India, and a Ph.D. in Sociology from Warwick University, UK. From 2007 to2009 she was an ESRC Research Asso-ciate at the Disaster and Development Centre (DDC) in Northumbria University, where she is now a Research Affi liate. Her research interestsinclude sociology of disasters, development, gender, resilience, liveli-hoods, health security, gender mainstreaming and qualitative meth-odology. Nibedita’s research works were published in several journals including Social Policy Administration, Environmental Hazards, Disasters, Health and Place, and Regional Development Dialogue. She also published a book entitled Caste, Class and Gender in Multiple Disasters: The Experiences of Women-Headed Households in an Oriya Village in 2009.

Pam Elardo is a section manager for the King County wastewater treatment utility serving the greater Seattle area. She is a professional engineer with over 20 years’ experience in regional and international infrastructure development. She worked as a water supply and sanita-tion engineer in Nepal as a Peace Crops Volunteer in the early 1980s. Since then, she has worked in the environmental engineering fi eld with the Washington State Department of Ecology and is currently employed as. In 1999 she established the Living Earth Institute (LEI) and has been actively involved with it ever since. Pam has managed LEI community development projects focused on water supply and sanitation in Nepal and Latin America. She holds a Bachelors degree in Chemical and Environmental Engineering from North-western University and a Masters degree in Environmental Engineering from the University of Washington.

Parnasri Ray Chodhury is an emergency and disaster risk reduction specialist for over a decade and participated in several humanitarian relief, rehabilitation and disaster risk programmes for UNICEF, UNDP, DIPECHO, Oxfam and National and State governments. She has an M.Sc. in Disaster Mitigation and a Post-Graduate Manage-ment degree holder with specialisation in Environment Management from Indian Institute of Social Welfare and Business Management,


Kolkata. Her main focus has been community-based disaster risk reduction and emergency public health promotion. Parnasri worked intensively in eight states of India and the Indian islands of Andaman and Nicobar Islands besides Bangladesh and also Nepal. She managed and implemented quite a few major DRR programmes for UNICEF, UNDP and DIPECHO and innovative public health programmes for Oxfam in India and Andaman and Nicobar Islands. She was earlierselected as a Core Committee member for conceptualising and de-veloping the National Guidelines for Minimum Standard by the National Disaster Management Authority of Government of India. She further worked as Convener of the Sub-Committee for Water Quality Standard.

Prakash Nelliyat works as Research Coordinator of the Crossing Boundaries Project at Centre for Water Resources, Anna University, India. Earlier he worked as Visiting Faculty at Centre for Envir-onmental Studies, Anna University; Research Associate at Madras School of Economics; Research Assistant/Associate at Madras Insti-tute of Development Studies and Academic Counsellor at Indira Gandhi National Open University. He obtained his Masters degree in Economics (University of Calicut), M.Phil. and Ph.D. in Envir-onmental Economics from the University of Madras through Centre for Research on New International Economic Order and Madras School of Economics respectively. His doctoral thesis was on ‘Industrial Growth and Environmental Degradation: A Case Study of Industrial Pollution in Tiruppur’. Prakash has more than 15 years’ research ex-perience in Water Resources and Environmental Management and received IWMI–TATA Water Policy Research Programme’s Young Scientist Award, 2006 (jointly with S. Mukherjee). He has presented a number of papers in conferences and published articles in edited books and journals. Prakash has received a grant for short term visit to overseas universities/institutes from the World Bank (India CapacityBuilding Project: Environmental Economics Overseas Fellowship Committee).

Papreen Nahar is a Research Fellow at the Department of Anthro-pology, Durham University, UK. She is also a research affi liate of


Disaster and Development Centre (DDC) at Northumbria University, UK. She did her Ph.D. in Medical Anthropology from the University of Amsterdam, The Netherlands. She has worked as a researcher at International Centre for Diarrhoeal Disease Research, Bangladesh, an international research organization in Bangladesh, between 1994 and 2007. Later she worked as an Assistant Professor at Dhaka Univer-sity, and later at Independent University, Bangladesh. Her research interest is socio-cultural, political and gender dimensions of health, particularly focused around reproductive health, climatic disasterand qualitative health. She has published a number of papers on infertility/childlessness and other health issues of women in different peer reviewed journals and a book. Along with other publications she has recently co-authored a paper ‘Contexualizing Disaster in Rela-tion to Human Health in Bangladesh’ in the Asian Journal of Water, Environment and Pollution.

Prachanda Pradhan is a consultant to Irrigation and Water Resources Management Project in Nepal funded by World Bank. He is Patron of Farmer Managed Irrigation Systems Promotion Trust, Kathmandu, Nepal. He is also member of Expert Panel of UNESCO on ‘Water and Culture Diversity’. He has several books to his credit, notably Patterns of Irrigation Organization, Case Study of 21 Farmer Managed Irrigation Systems in Nepal (1989, IIMI, Colombo), Local Institutions and People’s Participation in Public Works in Nepal (1980, Cornell University, Ithica, NY).

Sacchidananda Mukherjee is an Assistant Professor at the National Institute of Public Finance and Policy (NIPFP), New Delhi. He is working on environmental economics, water resources management and public fi nance related issues in India for last one decade Before joining NIPFP, he was with International Water Management Insti-tute (IWMI), Hyderabad and World Wide Fund for Nature-India, New Delhi.. Dr Mukherjee has studied at the Madras School of Eco-nomics, Chennai (Ph.D. in Economics from University of Madras) and Jawaharlal Nehru University, New Delhi (M.A. in Economics). His area of doctoral research is on Agricultural Non-point Source


Groundwater Pollution. He has conducted research projects funded by the Planning Commission, Government of India; IWMI, Colombo and published research papers in national and international journals. He has been consulted by the Indian Institute of Foreign Trade, New Delhi for several projects on environment. Dr. Mukherjee is a life member of Indian Society for Ecological Economics and a reviewer of Water Resources Management (Springer Journal).

Sajitha O.G. is the Chief Resource Person at the Teachers’ Resource Centre, Vakkom Moulavi Foundation Trust, Thiruvananthapuram, Kerala. She secured fi rst rank in M.Sc. and was awarded centrally administered ICSSR Doctoral Fellowship. She has received awards like Dr KCKE Raja Prize and Prof. Aliyamma Prize. Earlier, she worked as a faculty in Gujarat Institute of Development Research, Ahmedabad and the Indian Institute of Health Management Research (IIHMR), Jaipur. Her areas of interest include population, health and development. She has published several papers in many international and national journals.

Srihari Dutta is working as a Health Specialist in UNICEF Delhi. He is a specialist in public health and is trained in occupational health and environmental medicine and holds MD, DIH. He has pre-viously worked in UNICEF Orissa looking after child health pro-gramme and related operational research projects. He was WHO India country focal point for immunisation training and was the key technical resource person for writing the PNA report and Immunisa-tion handbook of Health workers published by Government of India. He worked as a State SMO for WHO–India Polio Eradication Project in Uttaranchal. He worked as a Senior Resident in the Department of Community Medicine of JIPMER, Pondicherry. He has more than 12 years’ public health experience mostly with UN agencies and was principal investigator of three major operational researches of national importance. He has published 14 papers in national and international medical journals. He has received Col Kripal Singh national award of Indian Psychiatric Society.


Shahzad Kouser is a research associate at the chair of International Food Economics and Rural Development, Georg–August University, Goettingen, Germany. She also teaches at the Department of Envir-onmental and Resource Economics (ERE), University of Agriculture, Faisalabad, Pakistan. She was awarded merit based Ph.D. scholarship from the Higher Education Commission of Pakistan in 2009. She is pursuing her Ph.D. research on ‘Economics of Pesticide Use and Biotechnology in Pakistan’s Cotton Sector’.. She completed her M.Sc. in Environmental and Resource Economics on ‘Economic Evalua-tion of Wastewater use in Caulifl ower Production with and without Externalities in Peri-Urban areas of Punjab, Pakistan’ with distinc-tion (Silver Medal). She has published several papers in nationally recognised journals and newspapers.

Sarmistha Pattanaik is involved in developing and establishing a spe-cial cell titled ‘Cell on Climate Change’ n IIT Bombay, India, whereher focus area includes the ‘climate change ethics’ in order to under-stand the larger issues on the perspective of vulnerability, social dimen-sions of the impact of climate change, more specifi cally the social construction of the problem in the developing nations, with reference to India and environmental ethics. She is an environmental sociologist and has done her Ph.D. in Development and Environmental Sociology from Jawaharlal Nehru University, Delhi. Later she joined the core faculty in the Centre for Interdisciplinary Studies in Environment and Development (CISED), ISEC, Bangalore (2006–08). She later moved to the Indian Institute of Technology (IIT), Bombay in 2008 and since then has been deeply involved in teaching interdisciplinary courses on environmental confl ict, social issues on environment, development and social movements. Her specialisations are politicalecology, environmental politics with a focus on social inequality and natural resource confl icts, marginalisation, environmental and indigenous social movements in India, sustainable development and climate change ethics. Most of her writings have focused on issues of displacement, impact of development projects on local community’s livelihood, health and ecology, their indigenous and social-political resistance and issues of sustainability.


Udaya Shankar Mishra is an Associate Professor at the Centre for Development Studies, Thiruvananthapuram. Dr Mishra is astatistician/demographer with a doctoral degree in Population Studies from the International Institute for Population Sciences, Mumbai and has served as a Takemi Fellow at the Department of Population and International Health, Harvard School of Public Health, Boston, USA. He has worked extensively in varied areas of research such as population health and development, gender and reproductive health as well as measurement issues concerning aggregation, inequality and assessment of progress. His current research interest includes issues concerning inequity, multidimensional aggregation as well as monitoring of development goals. His research work is published in several national and international journals including Health Policy and Planning, Journal of Human Development and Capabilities, Applied Economic Letters and Social Indicators Research.

Vishal Narain is Associate Professor at the School of Public Policy and Governance at Management Development Institute (MDI), Gurgaon. He holds a Ph.D. from Wageningen University, the Netherlands. His research spans a wide range of subjects in the realm of water policy and institutions, local governance and peri-urban issues. He is the author of Institutions, Technology and Water Control: Water Users’ Associations and Irrigation Management Reform in Two Large-Scale Systems in India’, published by Orient Longman in 2003. Besides, his research has been published in international refereed journals like Water Policy, Water International, Environment and Urbanization and South Asian Water Studies. He was also a lead author for a chapter on ‘Vulnerability of People and the Environment: Challenges and Opportunities’, for Global Environment Outlook–4, the fl agship publication of United Nations Environment Programme. He has recently completed con-sultancy assignments for International Water Management Institute, Colombo, STEPS Center, University of Sussex, U.K. and the South Asian Consortium for Inter-Disciplinary Water Resource Stud-ies, Hyderabad. Before joining MDI, he was with The Energy and Resources Institute, where among other activities, he edited Resources Energy and Development, an international, peer reviewed journal on natural resource management and development issues.


William Joe is a junior consultant at the health policy research unit of the Institute of Economic Growth, Delhi. He is registered with the Centre for Development Studies, Thiruvananthapuram for doctoral research in the area of measurement of health inequality and has obtained an M. Phil. degree in applied economics from Jawaharlal Nehru University. He has research interests in areas of health, envir-onment, human development and measurement of poverty and inequality. Some of his research outputs are published in reputed national and international journals including Journal of Human De-velopment and Capabilities and Economic and Political Weekly.

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