Table of Contents
Objective II - Long-Term Measures
Objective I - Immediate Relief Measures
A regional consultation of senior decision-makers and professionals from
national health and water supply authorities of Bangladesh and India as
well as international experts on Arsenic in Drinking Water and Resulting
Toxicity took place in the WHO South-East Asia Regional Office, New Delhi,
India, from 29 April to 1 May 1997.
The consultation provided an opportunity for the participants to exchange
experience and findings on the problems of arsenic poisoning on both sides
of the border between India and Bangladesh. It also provided a forum to
discuss the extent and the nature of the problem, as well as identify issues
and possible solutions to the problem. The health and environmental engineering
aspects were also discussed which led to recommendations for immediate
and long-term actions.
Based on the conclusions of this consultation, the present document
Recommendations for Action has been prepared. The purpose of this document
is to guide national authorities to prepare national action plans for providing
immediate relief to the victims and to develop long-term measures to tackle
a major public health hazard arising out of the presence of arsenic in
drinking water supplies in Bangladesh and India.
Arsenic is omnipresent inside the earth. Arsenic that comes to the surface
through exploitation of nature, such as agricultural irrigation withdrawing
underground water, geothermal power plants or mining, has seriously contaminated
the environment in Asia. Groundwater is the main source of drinking water
in India and Bangladesh. In the early 'eighties, arsenic contamination
of groundwater was detected in six eastern districts of West Bengal, India.
The arsenic concentration in groundwater in these districts ranged from
0.06 mg/l to 1.86 mg/l, far in excess of WHO's drinking water provisional
guideline value of 0.01 mg/l. It is estimated that over 150 000 people
are affected by arsenic and are suffering from 'arsenical dermatosis' (black
spots, eruptions and even cracking of skin). Similar problems have also
become apparent recently in Bangladesh in the areas bordering India, but
their geographical extent is yet to be defined.
In India both the state governments and the central government initiated
several actions in the past to mitigate the effects of arsenic in drinking
water. These included the establishment of working groups and an expert
committee, and the launching of a major water supply project. The governments
also identified the sources and causes of arsenic contamination as well
as its impact on public health, developed water treatment methods for arsenic
removal and recommended measures needed to supply arsenic-free drinking
water to populations at risk. Services of several experts from India's
specialized agencies and research institutions were used in these endeavours.
Recognizing the gravity of the situation resulting from arsenic contamination
of drinking water in Bangladesh, the Government in October 1996 convened
a special high-level interministerial meeting and constituted a National
Steering Committee with the Minister of Health as the Chairman. Various
international and donor agencies offered assistance. WHO also supported
the visit of a special mission to assist the Central Government and the
State of West Bengal, in India, in August 1996 and technical support was
provided to Bangladesh through WHO consultants in the last week of April
As it was felt that the two countries facing arsenic contamination of
groundwater would benefit from each other's experiences, a regional consultation
on "Arsenic in Drinking Water and Resulting Arsenic Toxicity in India and
Bangladesh" was convened at New Delhi, India, from 29 April - 1 May 1997.
The consultation brought together key scientific and technical persons
from Bangladesh and India as well as international experts for extensive
discussions on arsenic problems. A 20 Step Action Plan for achieving the
objectives of providing immediate relief to the victims and developing
long-term measures for effectively addressing this major public health
issue was the outcome of the consultation.
Recommendations for Action
Taking cognizance of the following facts:
Relief measures should be provided immediately through:
Arsenic in drinking water is a major public health hazard and should be
dealt with as an emergency situation;
"Affected people" are those who are showing clinical manifestations, and
"People at risk" are those who are drinking arsenic contaminated water
and do not necessarily show symptoms of arsenic poisoning.
Simultaneously, actions must also be initiated for developing long-term
measures based on the scientific assessment of factors contributing to
the arsenic problem and the identification of appropriate options for its
The supply of safe drinking water to all those affected and/or at risk
because of current exposure, and
Treatment of patients suffering from arsenic poisoning.
The implementation of both immediate and long-term measures should be
decentralized as much as possible with the active involvement of people,
affected or at risk, and of local community-based organizations.
Objective I - Immediate Relief Measures
Recommendation 1: Identify patients and/or populations at risk.
Organize the identification of patients as well as of the surrounding highly-exposed
Arsenic task forces of adequate strength need to be created to rapidly
identify patients with arsenic poisoning. Patient diagnosis of patients
will be achieved by detecting pigmentation, de-pigmentation or keratosis.
The goal will be to identify all the patients in one year.
When the patients have been identified, the surrounding wells should
be tested in order to ensure safe water for consumers and to prevent exposure
to those who, so far, do not have symptoms of disease.
Special effort should be made to identify arsenic exposure in children
and in pregnant and lactating mothers.
Recommendation 2: Provide symptomatic treatment
The immediate action for providing symptomatic treatment should include
taking care of skin problems, and providing vitamins and nutritious diet.
Serious problems should be referred to health centres or regional hospitals.
Recommendation 3: Provide medical care at health centres for seriously
Equipment and medicines must be available at the health centres for managing
seriously affected patients. Support needs to be made available for this
purpose from NGOs and international agencies (e.g. WHO, UNICEF and the
Recommendation 4: Strengthen diagnostic facilities at regional level
Many cases of arsenic poisoning are easy to diagnose. In more complicated
cases, however, laboratory facilities will need to be improved at the regional
level by providing such equipment as atomic absorption spectrophotometer
so as to determine the arsenic levels in water as well as human tissues.
For this, funds need to be made available from international agencies (e.g.
WHO, UNICEF, UNDP and the World Bank).
Recommendation 5: Provide safe drinking water
Immediate relief on emergency basis should be provided through the supply
of safe drinking water (e.g. using tankers and/or introducing domestic
treatment of water using appropriate methods of arsenic removal). Intensive
information, education and communication (IEC) activities should be undertaken
prior to introducing these methods and concurrent monitoring of the effectiveness
of these measures should be initiated.
In selecting the source of supply, the following order of preference
may be followed:
Organize rapid assessment of water supplies based on all available water
quality data and on cases of confirmed or suspected arseniasis so as to
identify the "hot spots" needing immediate supply of safe water. Sources
with arsenic levels above 0.05 mg/l should be clearly identified for priority
action (sources with the highest concentration receiving highest priority).
All unsafe sources should be marked and alternate sources of safe water
arranged for the community. Particular attention should be paid to patients
who should be advised to stop using the contaminated water source.
Tube wells proven to be safe (use piped supply or tankers for distribution,
Surface waters (e.g. ponds, rivers, canals) with appropriate and adequate
Rainwater harvesting and storage, using locally appropriate and hygienic
methods for domestic and community supply.
The arsenic-affected districts will require surveys of the existing
water supply for ascertaining the levels of arsenic. The surveys should
involve the following two steps:
All of the field data should be compiled, and analyzed and entered into
a national data bank. In addition to water quality data, hydrogeological
information should also be compiled in order to identify the arsenic-containing
and arsenic4ree aquifers. All this information should be entered into the
national arsenic data bank.
Comprehensive site investigations of all community and private sources
using appropriate and reliable field kits to find the presence or absence
of arsenic. Irrigation sources should also be evaluated for reference and
comparative information, and
Laboratory analysis of samples from site investigations so as to establish
the exact arsenic levels of field-tested sources.
Recommendation 6: Build capacity through training
Some patients may develop serious complications due to arsenic poisoning
but the untrained health personnel may not recognize these for many years.
Therefore, in areas having arsenic problems, training should be organized
for physicians, medical practitioners and other public health staff of
both governmental and nongovernmental bodies for rapid case identification
The key persons in each 'affected' and/or 'at risk' district should
be identified as the district-level key trainers (DLKTs) and should be
so trained. The DLKTs may include medical personnel, district planning
officers, executive engineers, hydrogeologists, college teachers, and NGOs,
etc. and should, in turn, train grass roots workers at local level.
Appropriate and comprehensive training programmes with curricula and
course materials should be developed by the recognized national and regional
Recommendation 7: Build awareness through mass communication
Intensive awareness-raising activities should be undertaken immediately
with regard to the negative health effects of drinking arsenic-contaminated
water in order to introduce preventive measures in cooperation with local
bodies, NGOs and others.
All avenues for increasing the awareness in this matter should be utilized,
including the mass media and communication facilities of government/ nongovernmental
organization(s). Specific posters, leaflets and other communication materials
should be developed for this purpose.
Recommendation 8: Implement comprehensive and integrated studies
The activities recommended above should be undertaken in an integrated
manner combining the medical and water supply interventions at the district
level in order to make the entire district population free from arsenic
risks. Comprehensive studies should be initiated in one district, each
in Bangladesh and India, with the support of UNICEF, UNDP, the World Bank,
WHO and other donors in order to demonstrate the effectiveness of implementing
Objective II - Long-Term Measures
Recommendation 9: Strengthen inter-ministerial coordination and cooperation,
and establlsh expert groups
A national apex committee should be formed to strengthen national level
interministerial coordination to address arsenic contamination of drinking
water; or if in existence, be modified as required to involve members of
the government and public interest groups effectively to jointly develop
policies and implement long-term strategies.
Expert groups should be established for identifying and addressing specific
technical and social issues, as required.
Recommendation 10: Establish national database on arsenic in drinking water
and resulting arsenic toxicity
Document the extent of the problem by collecting all the requisite information
generated by the investigation projects relating to drinking water supply
and health problems and evaluate the data.
Based on such an evaluation, strengthen the national database on arsenic
in drinking water. Establish a comprehensive management information system
(MIS) to facilitate monitoring and better planning and implementation of
The data generated by the rapid case identification programme should
also be stored and analysed centrally at an appropriate national institution
having computer facilities and should form an integral part of the national
database and MIS.
Recommendation 11: Review existing arsenic removal technologies and evaluate
A number of domestic and community water treatment methods have been developed
to remove arsenic in drinking water. A review and evaluation of the arsenic
removal treatment technologies and their efficiency should be undertaken
with WHO support.
Recommendation 12: Prepare detailed site-specific project proposals
Prepare detailed site-specific project proposals taking into account the
techno-economic feasibility, in order to facilitate the mobilization of
resources and donor support. Efforts should also be made to mobilize support
from the private sector and NGOs.
Recommendation 13: Identify training needs
Undertake situational analysis of training needs at different levels and
establish appropriate mechanisms for capacity-building and institutional
development. Include the subject of awareness of arsenic problems in the
educational curricula of medical and public health schools. Continuous
education of medical, engineering and laboratory staff should be ensured.
Recommendation 14: Establish appropriate institutional framework for water
An institutional framework needs to be developed for regular water quality
surveillance and control in the rural and pen-urban areas. A community-based
approach dealing with the grass-roots should form an integral component
of the programme.
Recommendation 15: Establish appropriate institutional framework for disease
An institutional framework needs to be developed for regular surveillance
and control of diseases arising out of arsenic poisoning.
Monitor the cases, identify the ongoing exposure and integrate the obtained
data with the information available from the drinking water quality surveillance
programme. A field kit for testing the presence of arsenic in urine needs
to be developed. Monitor the participation of affected persons, PHC personnel,
local self government personnel, and the urgent task force personnel. The
information, education, and communication activities should form an integral
part of the disease surveillance and control programme in order that the
general public and professional organizations are educated on the problem
of arsenic in drinking water. Integrate the arsenic-related disease surveillance
into other national disease surveillance programmes (e.g. National Cancer
Surveillance) and activities relating to nutrition and reproductive health.
Recommendation 16: Establish national reference laboratories
Establish national reference laboratories for undertaking the review and
evaluation of analytical techniques adopted for the determination of arsenic
in drinking water. Also ensure that the quality of data is assured.
Recommendation 17: Support research projects
The following research projects have been identified for support:
Assessment of clinical manifestations of chronic arseniasis and influence
of various factors on them.
Efficacy of drugs and other means of treatment of arseniasis, including
vitamins, nutritious diet, chelation agents and antioxidants.
Identification, through epidemiological studies, of the dose-response relationships
among skin manifestations in order to determine the safe level of arsenic
in drinking water.
Identification of factors which make populations susceptible to arseniasis,
Long-term cohort study of chronic arseniasis patients, to ascertain rates
of progression of latent complications, including cancer.
Assessment of the efficacy of recognized indigenous medicine and of homoeopathy
in treating chronic arseniasis.
Assessment of the risk of exposure to arsenic in the environment and the
Epidemiological study of the affected populations to assess the morbidity
patterns with special emphasis on the prevalence of arseniasis in children,
pregnant women and lactating mothers.
Arsenic removal treatment technologies and their efficiency and cost-effectiveness.
Recommendation 18: Assess the financial requirements at national, provincial
and local levels
The implementation of the recommendations will require financial resources.
Therefore, the financial requirements at the national, provincial, and
local levels will have to be assessed, keeping in view the broader perspective
of a well-coordinated integrated package of health environment and engineering
interventions using cost-effective and locally appropriate technologies
Recommendation 19: Establish bilateral collaboration
Establish bilateral collaboration between Bangladesh and India for the
exchange of geological, chemical, hydrogeological, epidemiological and
other technical information. Also establish collaborative visits and other
activities of mutual interest.
The exchange of ideas, research data and results of arsenic containment
activities should be fostered between governmental agencies, university
institutions, and research establishments of both countries.
Recommendation 20: Establish international cooperation and collaboration
In order to support the implementation of recommendations of this regional
consultation, international cooperation and collaboration are felt to be
essential. It is therefore, recommended that international agencies such
as UNICEF, WHO, UNDP, and the World Bank, etc. as well as bilateral donors
participate actively in the development of national programmes aimed at
addressing this major public health hazard.