A simple question about diabetes on a flight to Bangladesh leads to the story of “the largest mass poisoning in history” — arsenic in Bangladesh’s drinking water. And the role that two well-meaning donor agencies played in it.   

Have you ever had a day when disconnected things — conversations, images, thoughts — all somehow come together into something much larger and more interesting? A day of joining dots and seeing a pattern emerge? This happened to me last week, on the day I flew from Bangkok to Bangladesh. From the airport, the plan was to drive straight for five hours till we reached the district town of Bogura. On such long sojourns, I do three things mainly — talk, look, and ask questions. Usually one thing leads to another.

Dot 1: Something about sugar

The man sitting next to me on the flight to Dhaka had no rice on his plate. Not that he hadn’t eaten it; I could see he hadn’t been served rice. He muttered something but because his mouth was busy at the time, I only heard the word diabetes. Earlier I’d mistaken him for Amin Sayani, a well-know radio voice of yesteryear, and that had gotten us off to a good start.  He was a Calcutta boy, then a Delhi boy, but went to university in Karachi, though now his only son is married to a girl from Kerala. He thought Keralites were the most refined of Indians. I told him I was from Kerala, which was partly true, but not that refined, which was also partly true.

His family and friends were all over the plane, I realized, when a daughter, a grandson, a son-in-law and other kin swung by to check on him. Presently, a younger man from business class ambled up to chat with him, a friend this time, and my ears perked up when the word cropped up again — diabetes. As they exchanged woes, I reflected on the chances of meeting two men from two generations of two different Bangladesh families suffered from the same disease, and traveling on the same plane.

Dot 2: The driver’s diet

Shah Jahan became a driver with the United Nations Food and Agriculture Organisation less than a year ago. The division he is assigned to is intensely concerned with emerging infectious diseases, and Bangladesh has been endemic for avian influenza since 1983, so Shah Jahan tends to be on the road a lot, ferrying carloads of epidemiologists to distant hatcheries where birds are dying off.

Shortly after we left Dhaka city limits, we decided to stop for a bite to eat. Small town food in Bangladesh tends to be generally simply and tasty, though you need to check the hygiene standards yourself before taking a table. Generally, there will be rice or chapatis, a vegetable (bitter gourd is almost a standard), a dish featuring potatoes and raw papaya cooked together, a water thin dal made with red lentils, and either a chicken or fish curry for meat. There will be a cucumber salad, served with wedges of aromatic kaffir lime. Shah Jahan sat a different table from us, a reflection of Bangladesh’s bureaucratic awareness of social status and seniority/juniority.

On my way to washing my hands after eating, I noticed that he had skipped the rice and gone for the refined wheat flour chapatis instead. “Did you eat well?” I asked him in the car later. “I saw you didn’t eat rice.”

“I don’t eat rice, sir,” he replied. “I have diabetes.”

Shah Jahan is just a little over 40, too young to have diabetes. I asked him if he carried insulin injections around. No, sir, he replied, I take insulin tablets.

The third man with diabetes in as many hours. All from Bangladesh. Two of them too young to have diabetes. I whipped out my iPhone and went online as the car bumped along. Within moments I was looking at  some data from the Diabetic Association of Bangladesh. Professor Akhtar Hussain, diabetic researcher, wrote —

In 2010, the International Diabetes Federation (IDF) estimated that 5.7 million (6.1%) and 6.7 million (7.1%) of people living in Bangladesh is suffering from diabetes and impaired glucose tolerance (IGT) respectively. By 2030, that number of diabetic population is expected to rise to 11.1 million. This explosion in diabetes prevalence will place Bangladesh among the top seven countries in terms of the number of people living with diabetes in 2030.

Dot 3: Something in the tube well

We were passing vast plains of floodwater, a common sight in Bangladesh in the rainy season. The road, built on an embankment, rose above it all. Here and there, the topmost branches of submerged trees stuck out of the water, giving the landscape a surreal Dali-esque feel. Water reminded me of arsenic, and the number of times I’d heard about Bangladesh’s ubiquitous problem of arsenic in its drinking water. I also realized how little I knew about it. Was all water in Bangladesh contaminated? Did the arsenic find its way into the drinking water through industrial waste poorly disposed of? What did arsenic poisoning do to the body? Could arsenic be filtered out of drinking water?

I looked at the label on the bottle of mineral water in my hand — in fine print below the logo were the words Free of arsenic. For some reason, that sent a small chill through me. Well, that took care of the last question about filtering arsenic.

“The arsenic is everywhere,” said Arif, my colleague and traveling companion on this visit, “but specially near the big river.” The big river was of course the Ganges, on its way to a greater nirvana in the Bay of Bengal.

“Are we near the big river?” I asked, suddenly seeing a direct link between arsenic and myself. Our destination was the 140-acre campus of the Rural Development Academy in Bogura, Bangladesh. Would the water be safe? “They have their own arsenic filter on the campus,” Arif said reassuringly. This only alarmed me further: why would they install an arsenic filter unless the water there had arsenic?

We stopped at a roadside tea stall, with a tube well next to it. As he cranked water for tea from several hundred feet under ground, I noted that his pump did not carry anything that looked like it might be an arsenic filter. So while I pretended to drink my tea, I pulled out my trusty iPhone again and did some reading about arsenic in well water.

Dot 4: From arsenic to diabetes

The first thing I learned was that Bangladesh was only one among a slew of countries that had unsafe levels of arsenic in their well-water, others including the United States, Thailand and Taiwan. A 2007 study found that over 137 million people in more than 70 countries are probably affected by arsenic poisoning of drinking water. Approximately 20 incidents of groundwater arsenic contamination have been reported from all over the world. Of these, four major incidents were in Asia, including locations in Thailand, Taiwan, and Mainland China. South American countries like Argentina and Chile have also been affected. There are also many locations in the United States where the groundwater contains arsenic concentrations in excess of the Environmental Protection Agency standard of 10 parts per billion adopted in 2001. According to a recent film funded by the US Superfund, In Small Doses, millions of private wells have unknown arsenic levels, and in some areas of the US, over 20% of wells may contain levels that are not safe.

“Bangladesh had to change the limit otherwise they would have had to report that the entire country was at risk from arsenic poisoning,” said Arif cynically. The acceptable level as defined by WHO for maximum concentrations of arsenic in safe drinking water is 0.01 mg/L. The Bangladesh government set its limit at 0.05 mg/L. According to a British Geological Survey study in 1998 on shallow tube-wells in 61 of the 64 districts in Bangladesh, 46 percent of the samples were above 0.01 mg/L and 27 percent were above 0.050 mg/L. When combined with the estimated 1999 population, it was estimated that the number of people exposed to arsenic concentrations above 0.05 mg/L is 28-35 million and the number of those exposed to more than 0.01 mg/L is 46-57 million (BGS, 2000).

Bangladesh’s population is 142 million, according to preliminary reports from the latest census. This means nearly one-third of its population is exposed to unsafe levels of arsenic.

All riveting stuff, but I wanted to know what exactly happens to a person poisoned by arsenic. Easy — my iPhone reappeared in my hand, and a few taps later, I was looking at how I would be feeling if I’d been living in a village by the Ganges in Bangladesh —

Symptoms of arsenic poisoning begin with headaches, confusion, severe diarrhea, and drowsiness. As the poisoning develops, convulsions and changes in fingernail pigmentation called leukonychia may occur. When the poisoning becomes acute, symptoms may include diarrhea, vomiting, blood in the urine, cramping muscles, hair loss, stomach pain, and more convulsions. The organs of the body that are usually affected by arsenic poisoning are the lungs, skin, kidneys, and liver. The final result of arsenic poisoning is coma to death.

Arsenic is related to heart disease (hypertension related cardiovascular), cancer, stroke (cerebrovascular diseases), chronic lower respiratory diseases, and diabetes.

Dot 5: A case on unintended harm

There is very little evidence in Bangladesh to link arsenic poisoning with the increase in diabetes. Certainly, a major disease like diabetes can be linked to much more obvious causes such as poor diet, lack of exercises, genetic predispositions, and stress. Arsenic could be an exacerbating factor, no more. Or could it be more? In 2010, the British medical journal Lancet published a study led by Dr. Habibul Ahsan of the University of Chicago, which found that as many as 77 million people—half the population of crowded Bangladesh—may have been exposed to toxic levels of arsenic. Ashan and his colleagues followed nearly 12,000 Bangladeshis over the course of 10 years and found that more than 20% of deaths were caused by arsenic.

This had been predicted as early as 2000 by Dr Allan H Smith, professor of epidemiology at the University of California at Berkeley, USA, whose study forecast a major increase in the cases of diseases caused by arsenic ranging from skin lesions to cancers of the bladder, kidney, lung and skin, neurological effects, cardiovascular and pulmonary disease, and diabetes. The diseases, he warned, may develop slowly over many years. WHO called it “the largest mass poisoning in history”. The most detailed exposition I have read of the tragedy is here.

Based on these numbers, the three diabetes patients I had met today could easily be victims of a slowly blooming pandemic of arsenic poisoning. But by now my interest in arsenic was deep and urgent. Clearly there had been a time when Bangladesh’s drinking water did not contain arsenic  — so what brought it about?

I had the shocking answer before we reached Bogura. In the 1970s, nearly a quarter of a million Bangladeshi children were dying every year of a different disease — diarrhea — because of sewage-contaminated water from village ponds. Unicef, with the Bangladesh Department of Public Health and Engineering, proposed that water that was pumped out from deep ground through tubewells would be clean and safe to drink and not cause diarrhea. The World Bank pitched in with millions of dollars — and a massive tubewell construction project was launched in Bangladesh. Today over 3 million deep water tubewells pump up water to 97 percent of the population.

Unicef was telling its story  as recently as 1997, in a brochure of picture-postcard images of plump peasant women pumping well water: “During the 26 years since independence, the coverage record of the Bangladesh rural drinking water programme has been outstanding,” it said. “In spite of rapid population growth, 2.5 million public and private handpump tubewells have been installed, bringing safe drinking water to 97 per cent of the population.”

But alas, the story was false. Although the infant mortality in Bangladesh had halved by 1996, a different problem that affected anyone who drank water, had reared its head, first showing up as skin lesions and a burning sensation in the chest. Those who crossed the border into India for diagnosis and treatment were told that the symptoms corresponded to arsenic poisoning. The Bangladesh government, alerted, apparently stood in denial of the issue for some years rather than disrupt the well-funded tubewell programme.

The governments change, and each now is funded anew to address the problems created by previous governments and previous well-meaning donors. Everyone prospers, including the contractors hired to do the electrical and mechanical work. Everyone is better off, of course.

Except the 142 million people for whom all this is being done.