Every country has problems. Developing countries seem to have more than their fair share, due to an infinite number of variables. Developed countries provide a proportion of their total resources to help make life better for those in developing countries. There have been a number of organizations who make it a point to provide assistance to those in need, such as the World Health Organization and the United Nations.
No doubt a lot of the aid is needed and goes to bettering the situation for the people who are living (and dying) with serious deficits in basic human needs. Unfortunately, a lot of the aid provided to developing countries by developed countries or international aid organizations frequently is provided from the perspective of those in the developed countries. This means that sometimes, very important details get overlooked. The people working for these organizations can fail to consider the uniqueness of each place, and that can lead to horrible results for the people living in these unique places.
There are a number of examples of aid workers who neglect the uniqueness of the place they are trying to improve. A lack of complete understanding on the part of aid workers can lead to the failure of their program. It can also lead to devastating consequences for those who live in the aid-receiving country. Bangladesh is a country that has received a lot of aid through several programs; one of the programs has had a huge negative impact on the health of its population. Thirty-five million people in Bangladesh are using arsenic-tainted water for everything from drinking to irrigation (Chowdhury 2004). They are doing this because of a United Nations-headed initiative to provide safe water. Due to the workers’ lack of concern for the uniqueness of the place they were attempting to improve, the world’s largest mass poisoning has taken place.
The Initial Problem
Bangladesh’s population in the 1970s overwhelmingly used surface water as their source for drinking water (Caldwell 2003). The nation of Bangladesh had just been formed, and needed to face the fact that the use of surface water was not good for its people. It was an unhealthy source of water-borne disease and the fetching of water used a significant amount of time on the part of the women of the households (Ahmad, J. 2005).
Diarrheal and other water-borne diseases were (and still are) a leading cause of death and lost healthy days in Bangladesh (Lokuge 2004). They are especially deadly to small children, for whom “diarrhoea [sic] accounted for nearly half of all deaths” (Caldwell 2003:2089). Even now, diarrhea is the fifth-leading cause of death for Bangladeshi citizens (WHO 2003).
Another big reason that surface water was a poor source for drinking water was the time required to procure it. Women and girls in rural locations, especially in the southwest of the country – which is the driest area of Bangladesh – can spend up to half their day fetching water from rivers and streams (Caldwell 2003). A closer, more reliable source of water was thus seen to be desirable for two main reasons: to decrease infectious disease and to ease the burden on those responsible for obtaining the drinking water (mostly women).
So when the World Bank and the United Nations Children’s Fund offered to provide the supplies for building one million tubewells, the government leapt at the chance (Paul 2000). Please see figure 1 for a photograph of a tubewell. People were educated about the dangers of drinking surface water. After a while, individual households installed privately-owned tubewells, frequently with aid from other international organizations to help pay for their construction; this is referred to as the “ground water revolution” (Paul 2000). Besides providing adequate water for drinking, these tubewells also gave farmers enough water to spur on rapid agricultural growth, helping to provide more food for the population.
The tubewells installed were overwhelmingly drilled to be shallow. Both hand-pumped wells and the shallow tubewells typically tapped the aquifer somewhere between twenty and forty meters below the surface soil, which is easy to drill through (Caldwell 2003). Please see figure 9 for a graphic example. They became enormously popular, with 95% of rural Bangladeshis obtaining their drinking water from tubewells (Chowdhury 2004). A part of their appeal is that they could be installed “in a day or two at a price that nearly all households could afford” (Caldwell 2003:2090). The tubewells also had another attracting force: they are a symbol that the household has reached a certain level of prosperity and can afford to have a more modern source of water.
Tubewell installation picked up considerably in the 1980s and 90s. In 1983, chronic arsenic poisoning was first identified in Bangladeshis (Chakraborti 2002). Attention for the first cases is poor; the medical workers failed to recognize what the lesions on their patients’ skin meant. Please see figure 3 for a photograph of the discolored patches. Once arsenic was acknowledged to be the cause, it took until the late 1990s for the government and the international aid organizations to start the process of testing the water from the wells for it.
Arsenic can poison in two different ways. At high concentrations, it causes acute arsenic poisoning. Acute arsenic poisoning is characterized by nausea, vomiting, abdominal pain, diarrhea, dryness of the mouth and throat, sensory peripheral neuropathy, weakness, and changes to the skin and nails (Feinglass 1973). This is what people typically think of when they hear of arsenic poisoning. Most Bangladeshis are not suffering from this type of arsenic poisoning.
People who consume lower amounts of arsenic (but above 10 parts per billion (ppb)) are at risk for developing chronic arsenic poisoning. Unlike the acute form of poisoning, the effects of the arsenic when ingested at lower levels depends on the overall health of the person; in general, the healthier the person before long-term exposure to arsenic, the less likely they are to become seriously ill. Consequences of chronic arsenic poisoning are dire: liver, lung, kidney, bladder and skin cancer (Deshpande 2005). It also causes several other problems, like skin discoloration, gangrenous ulcers, keratosis, enlargement of internal organs, and disorders of various bodily systems, such as the gastrointestinal and neurological systems (Paul 2000). Please see figure 10 for a synopsis of chronic arsenic poisoning.
One of the major problems with chronic arsenic poisoning is that symptoms do not show up until about ten years after the beginning of exposure to the element. “Most of the existing wells are less than 10 years old,” leading to a significant concern that the current rates of cancer and other serious medical conditions are going to balloon in the future (van Geen 2004:6783).
Once testing started, it was clear that there is a significant problem with arsenic in the shallow tubewells. Inorganic arsenic compounds, which are more toxic than organic arsenic compounds, are the more common type of compound to find in water (Thirunavukkarasu 2005). In the United States, the maximum level of acceptable arsenic contamination is 10 ppb, which is also the recommended maximum level by the World Health Organization (Wasserman 2004). Bangladesh’s level is 50 ppb, but it does not make much of a difference. Please see figure 2 for a graphic showing the depths of wells and their arsenic concentration. About 37% of wells sampled have arsenic levels above 50 ppp (Chakraborti 2002). Please see figure 6 to see some of Chakraborti’s data. Approximately 43% of wells yield water with levels above 10 ppb (Sengupta 2003). This makes the total number of people exposed to dangerous levels of arsenic somewhere between thirty and forty million people at risk for developing arsenic-related illness (Wasserman 2004). Please see figure 4 for a map showing the distribution of arsenic-tainted wells in Bangladesh.
Reactions from Abroad
Despite early warning by pioneering physicians, epidemiologists and other medical workers, many aid and research organizations evidently ignored the advice being given. There are two examples of incompetence when applying, or unwillingness to put forth, the effort to truly understand the properties of the water in Bangladesh’s shallow aquifers. One involves the British Geological Survey, and the other implicates various aid organizations, including the World Bank, UNICEF, and WHO.
The British Geological Society (BGS) was one of the well-respected groups that helped put together the tubewell program. They installed many of the public wells that were put in during the eighties and early nineties (Chakraborti 2002). In 1992, the BGS performed a detailed study of the quality of the water in these wells. They neglected to check for arsenic (Chakraborti 2002).
The BGS had a lawsuit pending against it in the U.K. in 2002; it was eventually found not negligent by the court. The society was accused of being partly to blame for the poisoning due to its incomplete testing procedures (Chakraborti 2002). The BGS claimed that arsenic “was not then a recognized contaminant of groundwater” (Chakraborti 2002:16). Which is a bit surprising, seeing as arsenic in groundwater was reported as the cause of poisoning at a Minnesota factory in 1972; arsenic has certainly been seen as a health threat in the developed world for quite a while (Feinglass 1973). “WHO had identified waterborne-[arsenic] as a potential health threat by 1984,” Chakraborti asserts (2002:17).
Perhaps a bit more on topic, the BGS said that there was no indication of arsenic contamination in Bangladesh, or places with similar geology, prior to 1995 (Chakraborti 2002). This is also surprising to hear, seeing as arsenic contamination in groundwater from neighboring West Bengal, India, has been noted since 1983 (Rahman 2005). There were isolated cases of poisoning in West Bengal reported as early as 1964 (Chakraborti 2002). These reports should have caused some concern, seeing as both West Bengal and Bangladesh are both part of the same floodplain – the Ganga-Meghna-Brahmaputra plain (Rahman 2005). John McArthur, a sedimentologist at University College London, asserted “’most hydrogeologists worth their salt would have known about [the arsenic in West Bengal]’” (quoted Clarke 2001:556).
The BGS certainly knew about the risks of arsenic with regards to British wells. After WHO’s public concern about arsenic in drinking water was announced, the BGS analyzed all water tested in the United Kingdom for arsenic starting in 1989 (Chakraborti 2002). It is interesting to note that their tests in Bangladesh took place three years after these guidelines were set up; equally interesting is the fleeting mention by Chakraborti of work done by the BGS in Vietnam in 1996, when aquifer water testing did not include arsenic testing (2002). This is after the 1995 publicity generated by many articles hitting the international journals all at once. This is another indication that, not only do aid workers fail to consider the uniqueness of the country in which they are working, but they also are unsuccessful at applying objective, positivist research when appropriate.
Even if the BGS had managed to ignore the first reports of arsenic poisoning coming from Bangladesh, there was enough research done in nearby and fairly similar locations that they should have done an arsenic test in 1992. Their motivation for not doing so is unclear. There are two options: they were either negligent in performing the research necessary to know the area they were working to improve or they purposely did not do the arsenic testing for some reason (possibly that the tests would cost too much).
Unlike the British Geological Survey, UNICEF was not sued for their original help with putting in the tubewells (Clarke 2001). It should be noted, however, that arsenic was considered a safety hazard in well water by the medical community in the United States (Feinglass 1973). Their big scandal came with their inability to use a reliable and accurate test for arsenic in the field after arsenic had been established as a problem (Ahmad, K. 2002).
Ever since the arsenic story broke, there has been a huge push to develop field tests that can detect arsenic presence below 50 ppb. Please see figure 7 for a photograph of a field test kit that can detect lower levels of arsenic. Most Western countries have a safety standard for arsenic somewhere between ten and twenty-five ppb; even though Bangladesh’s level at the higher 50 ppb threshold, most international aid organizations consider that level potentially detrimental to consumers’ health.
Many international aid organizations started testing wells and funding well-testing projects in the mid-1990s (Ahmad, K. 2002). UNICEF, along with the World Bank and WHO, were crucial to the most recent wave of testing of wells. At the time, all of these groups used a Merck kit that could not tell if water had arsenic at the lower levels (Ahmad, K. 2002). It also has a real problem with accuracy. Results in the laboratory differed greatly from those the kit gave in the field; it was particularly wrong with wells in the 10-100 ppb range (van Geen 2005).
UNICEF and the World Bank should have been aware that the kits would not do the job they were asking it to do. Merck stated that their kit could not detect arsenic below 50 ppb (Ahmad, K. 2002). While the kits were probably useful for finding wells that had high levels of arsenic, laboratory testing should have been done on a significant subsample of the wells in order to “check up” on the testing kits. The results certainly should not have been used to declare wells safe or unsafe, but that is what they were used for (Ahmad, K. 2002). Wells were painted red for unsafe or green for safe, depending on the arsenic content given by the Merck testing kits. Please see figures 1 and 5 for examples of tubewells that have been painted. An estimated 52.5% of the wells were mismarked (Ahmad, K. 2002).
Social Impacts in Bangladesh
It took Bangladeshi people a long time to understand that drinking surface water was causing so much illness. After all, they had always used river water as their source of drinking and cooking water. Why should they trust foreigners who say that the water is not safe for drinking?
Actually, that message was not received by the majority of people who now use a tubewell as their source of drinking water. The main reasons most Bangladeshis chose to obtain (or at least use) a tubewell were that it cut down on the amount of work done to obtain water and that having a tubewell became a status symbol (Ahmad, J. 2005). Tubewells became a fairly cheap way to improve quality of life for the women of the household while showing one’s neighbors that one had the disposable income to spend on home improvements. Please see figure 8 for the prevailing Bangladeshi attitude towards shallow tubewells.
It is doubtful that most Bangladeshis, who do get their water from tubewells, are aware of the health issues that made aid organizations install them in the first place. They thus do not understand the fuss that is now being made over the wells. People have become panicked over the sudden appearance of well-testers, causing residents to be unduly scared when an explanation probably would have done much to allay their fears (Paul 2000).
A huge consequence of the failure of the aid organizations to educate tubewell users is that there are a lot of people who do not understand now what is going on. The last time these foreigners came to their village, the villagers were told that tubewell water was what they should drink; now, they’re being told that some tubewell water is not safe. This has created a credibility gap for the aid workers, and has added to their problems with getting Bangladeshis to follow the rules they put forth for using tubewell water (Paul 2000).
Most Bangladeshis do not understand why illness has occurred, and this has caused social problems. A significant number of those who are ill from chronic arsenic poisoning (about 90%) either do not know the reason or think that God has cursed them (Chakraborki 2002). Many who have been told that some wells are unsafe do not believe it because “the water has no foul smell . . . or taste” (Paul 2000:806). Some even think that a poisoned well means that a snake was struck while the well was being dug (Paul 2000). Obviously, education efforts about the arsenic problem have failed.
Women have been particularly affected by the negative associations made about arsenic poisoning victims. Parents are unable to find husbands for sick daughters, and women who are married frequently have husbands who either remarry or send them back to their parents (Chowdhury 2004). They are frequently shunned by the community and prevented from drinking from wells that have been deemed safe (Paul 2000). It is common that the lesions caused by the arsenic are mistaken for leprosy, and people with them are told by their community to not attend school, go to work, or visit health clinics as a result (Paul 2000).
Even those who have been educated find it hard to stop drinking from contaminated tubewells. Using a public tubewell – or, worse a neighbor’s tubewell – as a water source is a huge blow to the pride and social standing of a family (Paul 2000). Tubewells are a statement now in Bangladeshi society: they say that the household is doing well. To have to turn to another source causes a family to “experience a loss of prestige” (Paul 2000:807). It appears that there have been some people who, despite knowing the risks, have unsealed condemned wells to avoid having to use neighbors’ wells (Paul 2000). This development was potentially predictable by looking at the huge growth of the private tubewell market in the last decade – something that has become a big industry is probably something that people feel strongly about.
International aid organizations owe it to the country in which they are working to consider the particular characteristics of the country in which they are putting forth effort. If the organizations do not, there can be devastating consequences. This has been seen in Bangladesh, where the peculiarities of the country have been ignored time and again.
Bangladesh’s geology was ignored by everyone for twenty years. This resulted in the silent poisoning of thirty-five million people. After the public airing of arsenic contamination of groundwater, the organizations still bungled the aftermath. The British Geological Survey took no notice of the arsenic problem, even though they should have. UNICEF, the World Bank, and WHO made mistakes by using unreliable field tests for three years, accidentally making the problem worse by restricting access to safe wells and letting dangerous wells be used.
Even worse, the aid organizations today have not taken into account the poor quality of education and understanding in rural villages in Bangladesh. Workers have frightened and panicked villagers unnecessarily. Villagers, for their part, disregard a lot of what workers tell them because either it contradicts what they have been told by workers before or it is undesirable or impractical to do.
Bangladesh should be seen as a case study of what not do to when attempting to help. International aid organizations have to take into consideration the physical and social idiosyncrasies or the location before they start any sort of program. Especially when planning on changing food or water sources; there are too many things that can go wrong. Detailed studies should be done that deal with the aspects that are likely to change. It is the only way to be assured that catastrophic preventable events will not happen.