chapter i - harvard university department of...

Socio-Economic Consequences ofArsenic Poisoning in Drinking Water:

An issue of unprecedented cultural emergency

in BANGLADESH

Abul Barkat, Ph.DProfessor, Department of Economics,

University of Dhaka, Bangladesh(email: [email protected]; [email protected])

Prepared for presentation at32nd Session of the International Seminars on Planetary Emergencies,

Ettore Majorana International Foundation & Centre for Scientific Culture,in collaboration with

World Federation of Scientists & ICSC-World Laboratory

Italy, Erice 19-24 August, 2004

mailto:[email protected]

mailto:[email protected]

Socio-Economic Consequences of Arsenic Poisoning in Bangladesh: Cultural Emergency / Abul Barkat

Summary: About 50-70% of shallow tube-wells in Bangladesh are contaminated with arsenic beyond the permissible level of arsenic in drinking water (<=0.05 mg/l). Arsenic poisoning in drinking water has far reaching health effects, and social and economic consequences. Arsenicosis is a diseases of poverty; poors are disproportionately more affected; and once affected they get poorer, i.e., arsenicosis has created a new poverty-trap in Bangladesh. Arsenicosis - the clinical syndrome originating from high dose arsenic poisoning ranges from spotted melanosis (skin pigmentation at the 1st stage) and keratosis (thickening of skin of palm/ foot at the 2nd stage) up to gangrene and squamous cell carcinoma at the final (3rd stage). Different types of social and psycho-social problems may arise from arsenic poisoning– community refusal, discrimination, unhappy condition in conjugal life, problems in child development etc. A belief that arsenicosis is contagious, or similar to leprosy, has serious social consequences, especially for women and children who are abandoned by their families. Among the prevailing superstitions or false belief in arsenic affected communities, conceptions like ‘arsenicosis is a contagious disease’, or ‘cancer’, or caused by evil spirit’ or ‘God’s curse’, ‘sin’ – all there are highly pronounced in the communities. Economic loss to individuals, families and the nation- due to arsenicosis - is huge. Arsenicosis adversely affects the household income and consumption pattern. The income reduction effect, consumption shocks, and forced health expenses are the three major fronts through which economic burden of arsenicosis works. Vigorous behavioral change communication (BCC) and information-education-communication (IEC) campaigns should be undertaken to make people aware about the real causes and consequences of arsenic poisoning, as well as to disseminate available-within-reach low-cost mitigation strategies (use of filters for arsenic free drinking water and arsenicosis treatment facilities) to combat arsenic contamination. It would be highly effective to utilize over 100,000 staff of Ministry of Health and Family Welfare and similar huge number of NGO workers at the grassroot level for provisioning of arsenic-free safe drinking water filtration system to the people, as well as for identification, referral, treatment and follow-up of arsenicosis patient. In view of the increasing burden of arsenicosis– especially among the poor– the whole effort of arsenic mitigation should be considered as an essential part of the National Poverty Alleviation Strategy of Bangladesh.

Introduction

There is no denial the fact that chronic arsenic poisoning in drinking water is widely prevalent in Bangladesh. Estimates of people affected vary widely, and show that out of a total of 140 million people in Bangladesh, between 18 million (World Bank 1998) and 77 million people (Watanabe 1998) are at risk of arsenic contaminations; 14-20 million people are already affected showing visible signs. The British Geological Survey (1999) indicated that about 50-70% of shallow tube- wells in 61 of the 64 districts in Bangladesh are contaminated with Arsenic beyond the permissible level of arsenic in drinking water (<=0.05 mg/l).

Arsenic can produce serious health hazards if ingested in toxic amount. There are several reports showing deadly clinical and public health consequences of chronic arsenic poisoning in Bangladesh (Das 1998). From the nutritional and metabolic point of view, arsenic is likely to adversely affect human nutrition (Sarker 1999).

Although arsenic poisoning is a recently recognized environmental problem in Bangladesh, it has been prevalent in many parts of the world for quite sometime. The application of arsenic contained pesticides, chemical fertilizers and herbicides not only contaminate the soils and vegetation but also the air and surface water. The contaminated soils with arsenic generally results in the build-up of this toxin in the human food chain.

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Scientifically speaking, not much is known conclusively about the reasons for arsenic contamination in ground water, and extent of such contamination in Bangladesh. Also not known is the precise degree of social and economic consequences of arsenic poisoning by age -sex and economic status of our people. It is therefore, the depth and magnitude of social implications and economic consequences of arsenic poisoning should be identified before planning mitigation methods and/or intervention programmes. In the case of arsenic pollution in Bangladesh, it was rightly pointed-out that, while there are many research questions the top three priorities in the huge exposed population in Bangladesh related to stopping exposures are: providing easily accessible alternative water sources; making sure there is community understanding about the use of the alternative water sources; and population monitoring to ensure that the exposure have indeed stopped (Smith 1999).

Arsenicosis: a long-term disease process

Since last few years, several reports from many countries, including our neighbouring India, showed that several thousands people has been suffering from this devastating problem of arsenic pollution. Currently, Bangladesh has been identified as the worst arsenic affected country in the world.

Arsenicosis– the clinical syndrome originating from high dose arsenic poisoning– ranges from spotted melanosis (skin pigmentation at the 1st stage) and keratosis (thickening of skin of palm/ foot at the secondary stage) up to gangrene and squamous cell carcinoma at the final (3rd stage). More than 95% patients of arsenicosis, however, suffer from skin lesions of various spectrum (Akhtar et. al 1997, Mazumder et. al 1992). Some of the real life pictures of people affected by arsenicosis – melanosis, keratosis and gangrene, cancer – are exhibited in the next page (photographes by Dr. AKM Munir and the author).

Malnutrition among the children and women are widely prevalent in our communities particularly in the rural areas. However, in Bangladesh, little is known about the magnitude and the determinants of the problem. Although research initiatives have just begun, the impact of arsenic toxicity on human health in Bangladeshi population is largely unknown. We assume that there might be a relationship between arsenicosis and nutritional status of mothers and children; this notion is supported by the recent research studies (Rahman et. al 1999) that there is a relationship of arsenicosis with diabetes mellitus and hypertension.

Arsenic poisoning: the Bangladesh perspective

Several studies in shallow tube-well water in Bangladesh indicated that the 70% and 40% tube-wells are above the WHO and Bangladesh water quality standard of 0.01 and 0.05mg/litre respectively (DCH 1998, DPHE 1997). A report on arsenic monitoring in Noakhali district indicated that about 78% shallow hand tube-wells were about the Bangladesh standard of 0.05mg/l and all the deep tube-wells were below the Bangladesh standard (Das 1998). Recently several deaths due to severe arsenicosis have been reported in the National Dailies in Bangladesh.

Bangladesh, a poor (with per capita income of US $421) and densely populated (with 839 persons/km2) country, prone to natural disasters (flood, cyclones, disease), has been hit by this environmental catastrophe in recent years. Just after the arsenic contamination in India, a large volume of ground water, the major source of drinking water, has been severely contaminated by arsenic in Bangladesh (Akhtar et. al 1999, DCH 1998, Alauddin et. al 2000, Munir et. al 2001). This naturally occurring mineral, arsenic can cause serious ill health if ingested in toxic quantity. Though the lethal dose of arsenic ranges from 100- 125 mg/l (i.e., 1.2- 2.4 mg/ kg body weight), the permissible dose of arsenic in drinking water is only up to 0.01 mg/l as per WHO recommendation, however, in Bangladesh the permissible level is up to 0.05 mg /l.

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Arsenicosis patients in Kushtia district, Bangladesh

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A front page news in the New York Times (1998) reads “…Bangladesh is in the midst of a mass poisoning in history, dangerous level of arsenic have been found in the ground water, entering millions of people, sip by sip as they drink from over 4 million tube-wells.” The news continues “…if this were the United States, they’d call out National Guards and get everyone bottled water, …arsenic in drinking water poses the highest cancer risk ever found, we could be talking about hundreds of thousands of deaths- this is a medical emergency. In the truest sense of the term, this should be declared as a humanitarian emergency of unprecedented

scale and consequences”.

Public health importance of arsenic poisoning in groundwater

Arsenic pollution has recently been emerged as one of the serious public health concerns in Bangladesh. Though the country wide magnitude of the problem could not be assessed yet, it has however, been estimated by various national and international organizations ranging between 18 million to 77 million people are at risk of contracting arsenicosis.

‘Arsenic bringing people slow death’, ‘Mass poisoning using ground water’, ‘Poison water in Bangladesh’ - all such captions appeared in various national and international news media, over the past few years, give the evidences regarding the on-going catastrophic natural disaster of ground water pollution in Bangladesh causing much concern both for the people and the Government. The problem gained momentum as the days went on which became hard for the innocent poor people of Bangladesh to bear. It is obviously a tremendous task for the government to tackle this grave situation alone, since the problem entails clinical, environment, public health, nutrition, and socio-economic implications.

Apart from the health effects, arsenic poisoning also causes a wide range of social problems and economic loss. Therefore, it is of highest necessity to motivate these communities and make them aware that arsenicosis is not a ‘God made curse’ or the resultant of ‘sin’, neither it is ‘contagious’ nor a ‘infectious disease’. We must ensure that these patients are not neglected, demoralized or rejected by the surrounding communities, and, to prevent that, we need to educate the vast majority of these rural communities. But, towards taking these steps, we need to know the depth and magnitude of these socio-economic problems first, towards the understanding of social implications and economic consequences of chronic arsenicosis.

Considering the importance of the issue we conducted this study among the arsenic affected households in 3 districts of Bangladesh which generated several first hand information on the depth and magnitude of social implications and economic consequences due to chronic exposure to drinking arsenic contaminated water.

Objectives of the Paper

The broad objective of this paper is to disseminate the key findings of the research study entitled “Socio-economic Consequences of Arsenic Poisoning in Bangladesh”, conducted by the author as the principal investigator under the auspices of the University of Dhaka and Bangladesh Arsenic Control Society with financial support from The Ministry of Science and Technology, Government of Bangladesh. The specific objectives of the paper are as follows:

1. To strengthen our knowledge base about the social and economic consequences of arsenic contamination in groundwater; and

2. To assist the policy planners, academics and development workers in informed designing the arsenic mitigation policies and programs.

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Methodology

Since there is a distinct dearth of necessary knowledge-base on the economic and social consequences of arsenicosis an exploratory study was designed by the author, outcomes of which will set a foundation for the understanding of the issues involved, as well as for the subsequent relevant enquiries (studies) in the future.

The base-information on the subject were obtained from 274 sample households drawn from four arsenic affected upazilas: Kushtia Sadar, Bheramara, Hajigonj, and Pirgacha. Random sampling procedure was applied in selecting the sample households. The population (arsenic affected) list was obtained from the Bangladesh Arsenic Control Society (BACS). A total of 414 patients of arsenicosis were found in 274 sample households.

In order to collect all relevant data a structured questionnaire (with some open ended questions) was developed, pretested and administered. A total of 18 field staff was deployed in the field in (April 2001). All of them were imparted with intensive five days’ training on the subject, on relevant issues, and on questionnaire administration. Appropriate tabulation and analysis plans were developed. The data processing activities were performed using the services of a renowned social science research organization, the Human Development Research Centre.

Social and psycho-social consequences of arsenic poisoning

A wide range of social and psycho-social consequences are associated with arsenic poisoning in our society. Every fourth arsenic patient reportedly stopped to participate in social activities of the locality. A considerable portion of respondents (33%) reported that their neighbors dislike the arsenic patients’ participation in their social activities. More so, two-fifths of the respondents themselves reported that they or their family members, who are arsenic affected, fell shy or hesitate to participate in such social events.

In case of diseases and sufferings, women are found to be the worst victims because of negligence and discrimination. Women are ostracized in various ways – affected women are kept alone in separate room; neighbour come to visit or to talk to the affected women less than before; people look down and shows negligence to the affected women.

Over one out of three respondents reported that they faced restriction in sitting or sharing a bed with a non affected person. Reasons cited were as follows: spots or lesions in the body; unwillingness to sit or share a bed with a diseased person; consideration of the problem as infectious disease; fear.

Almost one-third of both the patients and the family members or their neighbours consider arsenic problem as a contagious or infectious disease.

Many people have misconception regarding the symptoms of arsenic poisoning. One-third respondents consider these symptoms as the symptoms of leprosy.

One-fifth of the respondents think that people consider arsenic poisoning as “God-made curse” or the “resultant of sin” and lack of education was mentioned as the main reason for such thinking by the people. Moreover, 12% consider that this is caused by evil spirits.

Over half of the respondents identified this problem as a threat to public health situation. The reasons cited were as follows: they think that death is the ultimate result due to long term suffering from arsenic poisoning; treatment for arsenic poisoning has not yet invented; the

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disease is spreading in and around the village like infectious disease; anyone may get that disease anytime; arsenic poisoning causes disability. Three out of five respondents reported that the arsenic patients had been suffering from mental agony because of their problem. Factors mentioned were mental anxiety and depression, the fear of a premature death, no remedy is known to anyone, constant physical weakness, loss of natural appearance or physical condition, fear of getting gangrene because of prolonged suffering from arsenic.

A high proportion of the respondents (55%) informed that a girl might face difficulties in getting married due to arsenic problem. The reasons mentioned were: girls look unattractive and less glamorous due to arsenic poisoning; nobody likes to get married with a patient girl; a newly married arsenic affected girl may act as transmitting agent of skin symptoms to the family members of bridegroom, and superstition.

About half of the respondents predicted that a marriage might be ended to a divorce if the wife gets arsenicosis. The anticipated reasons were: arsenic problem of a married women may deteriorate conjugal relationship with her husband and this reason may cause to an end of a relationship; husband may loss attraction to his wife because of his wife’s deteriorating physical situation; husband’s fear of getting infected from his wife.

Socialization as well as physical and mental development of a child in an arsenic affected family may hinder because of different reasons. A considerable percentage of respondents (42%) assume that unhappy family condition may lead to hamper child’s psychological and physiological development. About one-third of the respondents reported that arsenic affected children are avoided and/or refused to take part in the playground or schools by their mates.

Economic consequences of arsenic poisoning

Economics of consequences of arsenic poisoning has multiple dimensions which is still an unexplored area in the relevant literature. Thus, the subject on economic consequences of arsenic poisoning should be treated as an exploratory subject. However, the single most significant findings of the study revealed a highly disproportionate distribution of arsenicosis patients from the view point of family economic status: the poor (land poor and/or income poor) comprising 65% of the rural population constituted 96% of the total arsenicosis patients, and the non-poor comprising 35% of the rural population constituted only 4% of the total arsenicosis patients. Therefore, arsenicosis can be denoted as a disease of poverty (elaborated below).

About 57% of the affected persons have already switched from arsenic contaminated to new-non contaminated sources of drinking water. This implies that about 43% of the affected persons are still using arsenic contaminated tube-well as source of drinking water. The main reason for continuing to use the contaminated source was “non-availability of arsenic free tube-well” which, in most cases, was associated with the poverty of the households.

Switching from arsenic-contaminated tube-well to non-contaminated (or arsenic free) has distinct implication on time cost. Estimates show an 11-fold increase in the time-burden to obtain arsenic-free water compared to the earlier contaminated source. Before switching to the arsenic- free source, it took only about 20 minutes a day for an average household to obtain drinking water, and it has raised to about 220 minutes after switching to the (new) arsenic-free source. “Long distance to the new source” was cited as the main reason for such drastic increase in the time spent on fetching drinking water.

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About 25% of the respondents reported that they have incurred additional expenses for alternative source of drinking water. The mean amount of expenses incurred for the total sample was Tk.792. About 14% spent an amount ranging between Tk.3,001 and Tk.4,500, and 3 percent, between Tk.4,501 and Tk.6,000. The mean amount (for the total sample) spent on account of monthly maintenance cost was Tk.13.9. Thus, although a large majority – due to poor economic condition – did not incur additional expenses for alternative source of drinking water, the mean amount spent (for total sample) was high (one time Tk.792, and monthly maintenance cost, Tk.14).

Arsenicosis has affected adversely the overall income generation activities. Among the arsenic affected respondents 53% reported that their income generation activities were affected due to physical difficulties. About 48% reported that s/he or other affected members now earn income less than before, and thus the overall household income had declined. The contribution of the arsenic affected persons to the household income has dropped drastically from Tk.2,937 per month (on average) before-contamination to Tk.2,533 now (at the time of survey). More importantly, during the periods between pre-and post-affectedness, the average monthly household income of the affected households has declined from Tk. 4,258 to Tk. 4,022. People affected by arsenic poisoning contributed 69% of the total household income, and now (after arsenicosis) they contribute 63% of the total household income. In reality, the whole decline in the household income is attributable to the decline in the income of the arsenicosis patients.

The physical difficulties attributable to the declining income cited include inability to work as before due to physical weakness, loss of appetite due to arsenicosis, sleeplessness, body pain and itching, sore in legs, headaches, dizziness. Just 50% of the respondents reported that at least one of the working members of the household now devote less time in earning an income than before due mainly to physical difficulties associated with arsenicosis.

Occupational changes mediated through physical disability due to arsenicosis have also been reported in the survey. About 25% of the respondents reported that at least one of the earning members of the household was forced to change his/her occupation. The most dramatic part of the occupational change was evident in the extent of unemployment – about 10% reported unemployment of at least one earning member as a result of arsenic contamination situation. Such unemployment was not reported for before–contamination situation. The occupational change, although not much pronounced, were reported for such areas as agriculture (meaning cultivation), day labour, student, and hawker. Thus, it can be inferred that if appropriate timely actions are not taken there is every possibility of future large-scale unintended occupational changes which will not be in congruence with the necessary changing pattern of economic development. That in turn will create supply side problems to respond to the demand based occupational pattern of the rural economy of Bangladesh in the future.

Many respondents reported that arsenicosis patients are being discriminated in the labour market. Ten percent reported that arsenicosis patients are rejected in the labour market; and about 37% reported that arsenicosis patients get less wage/payment compared to those who are not affected (or effect not visible). As to the reasons for comparatively low payment to the arsenic affected workforce, about 53% said that it is attributable to the perception of the employer: they (employer) consider “arsenic affected people as less productive than those who are not affected with arsenic”.

Arsenic affected people are discriminated in terms of wage rates/daily payments, irrespective of gender. The male laborers used to get an average of Tk.83 as daily wage before being affected which went down to Tk.73 after being affected. The daily average wage rate for females was Tk.35 before being affected by arsenic and this rate went down to

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Tk.31 after arsenicosis. It is important to note that the wage rate has not only the distinct gender bias – women are less paid than men, but also the discrimination against women becomes more pronounced with the arsenicosis (because the rate of decline in wage due to arsenicosis is higher in females than in males).

Due to physical and social effects of the sufferings, the old aged people are in real trouble in contributing to the family income. About 73% of the respondents said that the affected old age people now contribute much less than before to the family income. Thus, the combination of old age with arsenicosis means an increasing deprivation and alienation for the old age people.

It is mainly due to the combined effect of decline in income and the need for treatment costs that the household food intake (consumption) pattern has been eroded in many families. About 41% respondents said that the family members eat low quality food at present than before having arsenicosis. This is further evident in the fact that the mean number of times of weekly intake of meat/fish have also declined – from 4.24 times (in a week) before being affected by arsenic to 3.59 times after the effect. This explains the deterioration of their nutritional status – leading to malnutrition, gradually.

Spending money on account of treatment of arsenicosis was reported by 41% respondents. As high as 73% respondents said that they have no money to comply with the proper treatment procedures, and therefore, they need more money for treatment. The average amount they were forced to spend (or expended) for treatment was Tk.2,125, but the reported requirement was Tk.4,452. Forty five percent of the respondents reported facing problems in arranging the money for treatment. Money for treatment was managed using various methods of “distress selling”, namely selling of livestock and poultry, withdrawal of capital from petty trading, selling of crop, mortgaging out/selling of land, taking loan from others. All these means, the economically poor arsenicosis households got poorer due to arsenicosis.

Based on the empirical findings of the study, it can be concluded that the problem of arsenicosis is more than just a problem, because arsenicosis is poverty–driven. Men, women and children in the poor households are disproportionately more affected than their counterparts in the rich households; children and adolescent are disproportionately more affected than the elderly; women are more affected than men; and in general, the poor are more affected than the rich. Empirical evidence also shows, that the arsenic affected poor people become poorer due to some major factors which can be denoted as arsenicosis-mediated poverty – a new kind of poverty trap in Bangladesh (Figure 1). The national implication of this economics of arsenicosis would be straight forward: people should be supplied with safe drinking water which is a Constitutional obligation of the State, and, therefore, considering the widespread poverty and gravity of the problem of arsenicosis – the whole issue pertaining to the supply of arsenic free safe drinking water to the people shall be considered as one of the major routes towards national poverty eradication in Bangladesh.

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Figure 1: Arsenicosis as Diseases of Poverty:Impact of drinking of arsenic contaminated water on Poor and Rich

Recommendations

Based on our overall understanding about the gravity of the Arsenic Poisoning situation in Bangladesh substantiated by the field-survey-based finding of this study, it would be pertinent and timely to forward the following recommendations for consideration by the competent authorities:

1. Bangladesh people in general (irrespective of rural and urban), and the victims of arsenicosis, in particular, are not adequately aware about the causes, consequences and mitigation possibilities of arsenic contaminated water and arsenicosis. They suffer from host of myths, misconceptions and misperceptions about the causes and consequences of arsenicosis. Thus, vigorous behavioral change communication (BCC) and information-education-communication (IEC) campaigns should be undertaken to let people know about the causes and consequences of arsenicosis, and the mitigation strategies through using locally available and scientifically proven low-cost technologies (including treatment facilities) of arsenic contamination. Electronic media (such as TV and Radio) and print media (such as newspaper) including pictorial presentation (due to high illiteracy among rural poor) should be assigned with high priority to reach the rural populace.

2. The government’s Health, Population and Nutrition Sector Programme (HPNSP) is designed to meet the public health demand of the poor people through provisioning of primary health care and essential services package (ESP) at the sub-district level

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Overall poverty aggravates(both income and human poverty)

Most are not affected due to better nutrition,

education-based awareness, and ability to install new tube-wells

Some are affected, but they mitigate quickly by installing new

tube-well and through medical

treatment

Poor

Most are affected because of less

nutrition

Some not affected are just passing the incubation period i.e., they will also be affected in due

course (if measures are not taken)

Once affected Productivity reduces,

Wages reduces, Psycho-social effect maximizes,

Health expenses increases

Household food consumption reduces, Children isolated from school,

Women alienated

Rich


and below. The predominant majority of our population also live in sub-district and below. Thus, it would be highly cost effective to utilize the grassroot level over 100,000 staff of Ministry of Health and Family Welfare (FWA, HA, FWV, FPI, AHI, HI etc) as well as the similar number of NGO workers in popularizing the arsenic-free filter system, as well as for the identification, referral, treatment and follow-up of arsenicosis patients. Essential training and motivational services for these service providers on related issues should be institutionalized. Appropriate collaboration with the local government bodies (union councils), NGOs and CBOs is highly recommended to expedite the whole process of mitigation, and identification, referral, treatment and follow-up of arsenicosis patients.

3. All the arsenic affected people, irrespective of poor or rich, have shown their interest and willingness to participate in the community-based initiatives that can be taken for switching from As-contaminated to arsenic free water. Thus, all available means and ways should be promoted to materialize social mobilization through people’s real participation in installation and maintenance of arsenic-free sources of drinking water, as well for the creation of an conducive “humane” environment for these in the community who are victims of arsenicosis. Means and ways should worked out to restore the respect to the people living with arsenicosis (PLA) (there has been a gross denial of social respect to PLAs).

4. Economic loss to individuals, families and the state due to arsenicosis, as estimated in this study, is huge. Arsenicosis adversely affects the household income and consumption pattern. The income reduction effect, consumption shocks, and forced expenses for arsenicosis treatment are the three major fronts through which economic burden of arsenicosis work. A nation-wide large scale study will be of high utility to assess the real burden of arsenicosis on various socio-economic segments, age groups, occupation, and gender. Such study should be designed in such a way to provide a national data bank to facilitate the estimation of real burden of arsenicosis, estimation of disability adjusted life years (DALY) and quality adjusted life years (QALY), as well as to provide the basis for planning and monitoring of arsenicosis-related diseases burden. In view of the increasing burden of arsenicosis this should be considered as an essential part of the National Poverty Alleviation Strategy of Bangladesh. And, finally, the whole issue of arsenic mitigation – by ensuring supply of arsenic free safe drinking water using scientifically proven filtration system and treatment of arsenicosis patients – should be accepted as one of the key strategies for the National Poverty Eradication in Bangladesh.

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SELECTED REFERENCES

Ahmed MF (2000). Strategic Plan for Arsenic Mitigation in Bangladesh. Bangladesh Environment 2000. A compilation of papers of the International Conference on Bangladesh. Environment-2000 (ICBEN-2000). BAPA, BUET. Dhaka.

Akhtar A, P Bandernayake, AK Wadud et al. (1997). Arsenic contamination in ground water and arsenicosis in Bangladesh. Int’l J Environ Health Res. 7 (4): 271-276.

Akhtar A, SMH Sallimullah, Sk. Hadi, et al. (1999). Arsenicosis in a village of Bangladesh. Int’l J Environ Health Res. 9 (3).

Alauddin M, A Hussam, AH Khan, M Habibuddowla, SB Rasul and AKM Munir (2000). Critical evaluation of a simple arsenic removal method for ground water of Bangladesh. 4th International conference on Arsenic Exposure and Hazards, SanDiego, calfornia, USA.

Barkat A, AKM Maksud, KS Anwar and AKM Munir (2002). “Social and Economic Consequences of Arsenicosis in Bangladesh”, in MF Ahmed, SA Tanveer and ABM Badruzzaman (eds), Bangladesh Environment, 2002, Vol. 1, Bangladesh Paribesh Andolon, Dhaka.

Barkat A, KS Anwar, AA Molla, A Hossain, AKM Maksud and AKM Munir (2001). Socio-Economic Consequences of Chronic Arsenic Poisoning in Bangladesh, University of Dhaka and Bangladesh Arsenic Control Society, prepared for the Ministry of Science and Technology, Government of Bangladesh.

British Geological Survey and Ministry of LGRD (1999). Ground water studies for arsenic contamination in Bangladesh. Final Report. Phase I: Rapid Investigation Phase, Government of Bangladesh.

Das HK (1998). Arsenic pollution and its severity in Bangladesh (In Bengali), Bangladesh Centre for Advanced Studies. Science Magazine of Bangla Academy: Kartik-Chaitra, 1404.

Das HK (1998). Report on Arsenic Monitoring in Noakhali Paurashava, Laboratory of the DPHE-Danida Urban Water and Sanitation Management unit, Noakhali.

Dhaka Community Hospital (1998). The Arsenic problem in Bangladesh: An introduction to the country and its arsenic situation. Abstracts. International Conference on Arsenic Pollution of ground water in Bangladesh: Causes, Effects and Remedies. LGED Auditorium, Dhaka, Bangladesh, 8-12 February, 1998.

Dhar RK, KB Biawas, G Samanta et al. (1997). Ground water arsenic calamity in Bangladesh. Current Science, vol.73, No.1, pp.48-59.

Khan AH, SB Rasul, AKM Munir, M Alauddin, M Habibuddowlah and A Hussam (2000). On Two Simple Arsenic Removal Methods for Groundwater of Bangladesh. Bangladesh Environment 2000. A compilation of papers of the International Conference on Bangladesh. Environment-2000 (ICBEN-2000), BAPA, BUET, Dhaka; p.151.

Mazumder G, DS Gupta, DJ Chakrabarti, et al. (1992). Environmental pollution and chronic arsenicosis in south Calcutta. Bulletin WHO, 70 (4): 481-485.

Munir AKM, SB Rasul, M Habibuddowla, M Alauddin, A Hussam and AH Khan (2001). Evaluation of Performance of Sono 3-Kolshi Filter for Arsenic Removal From Ground Water Using Zero Valent Iron through Laboratory and Field Test, in Bangladesh Environment 2001, ed. M Feroze Ahmed, BUET and UN University, Tokyo, Japan.

Nayeem GW (1999). Booklet on Disaster in Bangladesh. Disaster Forum, Dhaka.

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Rahman M, M Tondel, et al. (1998). Diabetes mellitus associated with arsenic exposure in Bangladesh. Am J Epid 249,189-203.

Rahman M, M Tondel et al. (1999). Hypertension associated with arsenic exposure in Bangladesh. Hypertension. 33:74-78.

Sarker B (1999). Arsenic Crisis in Bangladesh: a personal experience. International Conference of arsenic in Bangladesh Ground Water: World’s Greatest Arsenic Calamity. Bangladesh Chemical and Biological Society of North America (BCBSNA)-Intronics Technology Center, Dhaka. Feb 27-28. Wagner College (Spiro Hall), New York, USA.

Smith AH (1999). Arsenic in Bangladesh: The need for urgent action to reduce major disease impacts. International Conference of arsenic in Bangladesh Ground Water: World’s Greatest Arsenic Calamity. Bangladesh Chemical and Biological Society of North America (BCBSNA)-Intronics Technology Center, Dhaka, Bangladesh. 27-28,. Wagner College (Spiro Hall), New York, USA.

The New York Times (1998). Front Page News. 10th November,.

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