Ecotoxicology and Environmental Safety 150 (2018) 335–343

Contents lists available at ScienceDirect

Ecotoxicology and Environmental Safety

journal homepage: www.elsevier.com/locate/ecoenv

Review

Human health risks and socio-economic perspectives of arsenic exposure in T

Bangladesh: A scoping review
⁎
M. Azizur Rahmana,b, , A. Rahmanc, M. Zaved Kaiser Khanc, Andre M.N. Renzahod
a
Center for Infrastructure Engineering, Western Sydney University, Australia
b
Faculty of Science and Technology, Federation University, Ballarat, Victoria, Australia
c
Water and Environmental Engineering, School of Computing, Engineering and Mathematics, Western Sydney University, Australia
d
Humanitarian and Development Research Initiative, School of Social Sciences and Psychology, Western Sydney University, Australia

A R T I C L E I N F O A B S T R A C T

Keywords: Arsenic contamination of drinking water, which can occur naturally or because of human activities such as
Arsenic exposure mining, is the single most important public health issue in Bangladesh. Fifty out of the 64 districts in the country
Socio-economic have arsenic concentration of groundwater exceeding 50 µg L−1, the Bangladeshi threshold, affecting 35–77
Socio-cultural million people or 21–48% of the total population. Chronic arsenic exposure through drinking water and other
Public health
dietary sources is an important public health issue worldwide affecting hundreds of millions of people.
Bangladesh
Consequently, arsenic poisoning has attracted the attention of researchers and has been profiled extensively in
the literature. Most of the literature has focused on characterising arsenic poisoning and factors associated with
it. However, studies examining the socio-economic aspects of chronic exposure of arsenic through either
drinking water or foods remain underexplored. The objectives of this paper are (i) to review arsenic exposure
pathways to humans; (ii) to summarise public health impacts of chronic arsenic exposure; and (iii) to examine
socio-economic implications and consequences of arsenicosis with a focus on Bangladesh. This scoping review
evaluates the contributions of different exposure pathways by analysing arsenic concentrations in dietary and
non-dietary sources. The socio-economic consequences of arsenicosis disease in Bangladesh are discussed in this
review by considering food habits, nutritional status, socio-economic conditions, and socio-cultural behaviours
of the people of the country. The pathways of arsenic exposure in Bangladesh include drinking water, various
plant foods and non-dietary sources such as soil. Arsenic affected people are often abandoned by the society, lose
their jobs and get divorced and are forced to live a sub-standard life. The fragile public health system in
Bangladesh has been burdened by the management of thousands of arsenicosis victims in Bangladesh.

1. Introduction experiencing “the largest mass poisoning of arsenic of population in

Arsenic is ubiquitous in the earth's crust, although generally con-
stitutes less than 1% of most rocks, coals, and soils (Alam et al., 2002).
Although the occurrence of arsenic in the environment is mainly from
minerals and geogenic sources, human activities resulted in extensive
soil and water contaminations in many parts of the world (Smith et al.,
1998).
Groundwater contamination with high level of arsenic is an im-
portant environmental and public health issue in South and South-East
Asian countries (Chakraborti et al., 2015). It is the single most im-
portant public health problem in Bangladesh, with between 35 and 77
million of its population being at risk of arsenic poisoning from arsenic-
contaminated drinking water (Edmunds et al., 2015). In 2000, the
World Health Organization (WHO) stated that Bangladesh has been
history” (Smith et al., 2000).
The rural people of Bangladesh have mainly depended on surface
water to meet drinking water needs. Such surface water has often been
contaminated by pathogen. However, from the 1960's hand-pumped
tube wells were widely introduced in the rural areas of Bangladesh
especially by government and non-government agencies to provide
pathogen-free drinking water. This practice accelerated significantly
from the 1980s onwards as the installation of tube wells became rela-
tively cheap and the technology became easily available (Edmunds
et al., 2015). This led to a significant increase in the access of under-
ground drinking water from the shallow alluvial aquifers (Smedley and
Kinniburgh, 2002) (Fig. 1).
Chronic arsenic poisoning was first identified in West Bengal of
India in the 1980s; however, the first diagnosis of arsenic poisoning in

⁎
Corresponding author at: Faculty of Science and Technology, Federation University, Ballarat, Victoria, Australia.
E-mail addresses: rahmanmazizur@gmail.com, mohammad.rahman@federation.edu.au (M.A. Rahman).

https://doi.org/10.1016/j.ecoenv.2017.12.032
Received 30 June 2017; Received in revised form 13 December 2017; Accepted 14 December 2017
0147-6513/ © 2017 Elsevier Inc. All rights reserved.
M.A. Rahman et al.
Bangladesh was made in 1993. It was reported that more than a quarter
of shallow (< 150 m deep) tube wells in Bangladesh contained at least
50 mg L−1 arsenic. The worst-affected area is the South-East region of
the country, where more than 90% of the tube wells were arsenic-af-
fected (Smedley and Kinniburgh, 2002).
Although groundwater is the main source of drinking water, it is
also an important source of irrigation water in south and south-east
Asian countries (Meharg and Rahman, 2003). Underground water has
been used extensively, particularly during the dry season, for rice cul-
tivation in Bangladesh (Meharg and Rahman, 2003). The background
levels of arsenic in paddy-growing soils in Bangladesh range from 4 to
8 mg kg−1; however, up to 83 mg kg−1 of arsenic was found in paddy-
growing soils that was irrigated with arsenic-contaminated ground-
water (Williams et al., 2006). High level of arsenic in paddy-growing
soils from contaminated irrigation water has resulted in arsenic uptake
in rice grain (Rahman and Hasegawa, 2011; Williams et al., 2006) and
vegetables (Alam et al., 2003; Rahman et al., 2013) that raised concern
of potential human health risk in the country. The possibility of arsenic
exposure to the people of the countries where arsenic contamination
has not been occured can be an important concern with the expansion
of global food trade (Rahman et al., 2014).
Widespread human exposure of arsenic from drinking water and
food and associated carcinogenic and non-carcinogenic effects have
336
Ecotoxicology and Environmental Safety 150 (2018) 335–343
Fig. 1. Map showing the distribution of arsenic in
groundwater of Bangladesh, adopted from Smedley
and Kinniburgh (2002) with permission.
been matters of growing concerns during the past three decades
(Chatterjee et al., 2010; Rahman et al., 2009). Besides the public health
impacts of arsenicosis, arsenic contamination may create widespread
socio-economic consequences for the victims and their families in
Bangladesh; however, this issue has received little attention from the
point of view of social risk and hazards. Therefore, the purpose of this
review is to fill in this knowledge gap with special reference to Ban-
gladesh. The specific objectives of this paper are to:
■ Discuss dietary and non-dietary pathways of arsenic exposure.
■ Identify the socio-economic consequences of chronic arsenic ex-
posure in Bangladesh considering food habits, nutritional status,
socio-economic conditions, and socio-cultural behaviours of the
population of the country.
■ Identify the social risk and social hazards of arsenicosis.
2. Methodology
A scoping review has been conducted following the framework
outlined by Arksey and O'Malley (2005) and Levac et al. (2010). The
framework outlined five steps that we implemented in this study:
Identifying the research question; identifying relevant studies; selecting
previous studies; charting the data; and collating, summarizing and
M.A. Rahman et al.
reporting the results.
In step 1, we defined our research question as follows: What are the
public health impacts of chronic arsenic exposure and the socio-eco-
nomic consequences of arsenicosis in Bangladesh? In step 2, previous
studies were identified through a selection of electronic databases, fo-
cusing on peer-reviewed publications, supported by citation tracking
and hand searching. The target electronic databases were: Goggle
Scholar, SCOPUS, Web of Science, and PubMed. Using a combination of
keywords agreed upon by the research team and confirmed by MeSH
terms and sub-headings associated with them, the search strategy was
implemented. Data were extracted according to whether or not the
study addressed our research questions.
Over 683 research papers/documents were retrieved from the da-
tabase of which, 60 papers were used in this review based on their
relevance to the study research questions (Fig. 2). Year of publication,
impact of the journals, study locations (mainly Bangladesh), and re-
liability of reported data in the documents were also considered in se-
lecting the papers. Daily dietary intake (DI) of arsenic from different
foods was calculated based on the following formula:
DI = DFC × MC (1)
where, DFC is the daily food consumption rate (g/day), and MC is the
mean arsenic concentration (µg/g fresh/dry weights) in individual food
stuff. Dietary intake was calculated for individual adult male and fe-
male.
Qualitative data from multiple sources, as described by Hassan et al.
(2005), were used to determine impacts of arsenic exposure on social
lives of affected Bangladeshi population and their survival strategies.
337
Ecotoxicology and Environmental Safety 150 (2018) 335–343
Fig. 2. PRISMA flow diagram for the scoping review process.
3. Result and discussion
3.1. Arsenic exposure to human
Arsenic-contaminated tube-well water is the main source of arsenic
exposure to Bangladeshi adults; however, other important exposure
pathways for arsenic include plant media (rice and vegetables), animal
source foods, water, and non-dietary sources such as air and soil
(Fig. 3).
3.1.1. Dietary sources
Plant media as an exposure pathway for arsenic occur in various
forms including food preparation and consumption. Water used for the
preparation of foods (e.g. rice and vegetables) and beverages (e.g.
beverages prepared using arsenic-contaminated water) represents an
indirect route of arsenic exposure (Joseph et al., 2015a). In addition,
the animal source foods such as milk, eggs and meat are potential ex-
posure pathways for arsenic (Ahmed et al., 2016).
In Bangladesh, rice is the major staple food accounting for up to
80% of the daily caloric intake (Huq et al., 2006) with an average daily
rice consumption of 400–650 g (Rahman et al., 2006), which is among
the highest per capita rice consumption figures in the world (Abdullah
et al., 2006). On average, arsenic concentration in Bangladeshi rice
ranges from 0.1 to 0.95 µg g−1 (Williams et al., 2005). With a total
arsenic content of 0.1 µg g−1, consumption of 650 g rice per day would
translate into an ingestion of 65 µg or 0.065 mg arsenic, which is the
highest among all dietary sources. It is worth mentioning that rice ab-
sorbs approximately twice its weight in water during cooking process,
thus, arsenic levels in cooked rice is likely to be higher if the cooking
water is contaminated by arsenic (Rahman et al., 2006; Sengupta et al.,
2006). Based on past studies, the estimated retention of total arsenic in
cooked rice can be between 45% and 107% (Joseph et al., 2015a) de-
pending on the rice types, arsenic concentration in cooking water, and
M.A. Rahman et al. Ecotoxicology and Environmental Safety 150 (2018) 335–343

Fig. 3. Different exposure pathways of arsenic to human, adopted from Rahman et al. (2008) with permission.

the methods of cooking. Commonly used traditional rice cooking
method in Bangladesh includes parboiling, and washing of raw rice and
then cooking it with excess water followed by gruel decant. This
cooking method is likely to reduce arsenic exposure from rice diet
(Rahman et al., 2006).
Other important issues related to arsenic exposure from rice diet are
concentration and bioavailability of arsenic species in rice (Laparra
et al., 2005). On average, 50% of the total arsenic in rice is inorganic,
the most toxic form of arsenic, which can vary from 10% to 90% (Zhu
et al., 2008). The absolute bioavailability is the highest (103.9%) for
arsenite followed by arsenate (92.5%), dimethylarsenate (DMA)
(33.3%), and monomethylarsenate (MMA) (16.7%) (Juhasz et al.,

338
M.A. Rahman et al.
2006). Therefore, human health risk of inorganic arsenic species is
greater than organoarsenic species.
In case of vegetables, arsenic exposure to human is directly pro-
portional to the vegetable consumption rate and arsenic concentrations
in vegetables. Typically, root vegetables accumulate and store arsenic
in their root tuber, while arsenic translocation to the above ground
parts is generally limited (Rahman et al., 2013). Although arsenic
concentrations in most of the vegetables did not exceed 4 mg kg−1 dry
weight (dw), some vegetables contained up to 8 mg kg−1 dw (e.g.
gourd leaf) and 158 mg kg−1 dw (e.g. peeled arum root) arsenic.
Arsenic concentrations in leafy and non-leafy vegetables in
Bangladesh ranged between 0.1–2.0 mg kg−1 wet weight (ww) and
0.1–0.8 mg kg−1 ww, respectively (Tani et al., 2012). Another study
reported arsenic concentrations in leafy and non-leafy Bangladeshi
vegetables ranged between 0.04–0.46 mg kg−1 ww (median is
0.11 mg kg−1 ww) and 0.011–0.15 mg kg−1 ww (median 0.03 mg kg−1
ww), respectively (Rahman et al., 2013). The per capita vegetables
consumption in Bangladesh is reported to be 238 g/person/day (Joseph
et al., 2015a) indicating that the consumers could be exposed to
26.18 mg and 7.14 mg of arsenic per day from their leafy and non-leafy
vegetable diets, respectively. The above data suggest that in addition to
water and rice, vegetables could be an important dietary source of ar-
senic exposure for Bangladeshi individuals.
Animal source foods such as meat, fish, and milk are the major
dietary sources of arsenic in Bangladesh. Arsenic concentrations in
animal-origin Bangladeshi foods have been reported as
0.20–0.27 mg kg−1 dw (mean is 0.20 mg kg−1) in chicken meat (Ghosh
et al., 2012), 0.61–0.88 mg kg−1 dw in mutton meat,
0.41–0.67 mg kg−1 dw in beef meat (Tarafdar et al., 1991),
0.097–1.40 mg kg−1 dw (mean 0.40 mg kg−1) in fish (Islam et al.,
2014), and 0.004–0.16 mg L−1 (mean 0.04 mg L−1) in cow milk
(Ghosh et al., 2013). Dietary intake of arsenic from animal-origin foods
depends on the daily consumptions of these foods. The consumption
rates of beef, mutton, chicken and duck meats in Bangladesh are
4.77–12.63 g/day, 0.5–0.89 g/day, 9.01–17.42 g/day, and
5.31–13.42 g/day, respectively (Ahmed et al., 2016). Based on this
data, the estimated daily dietary intake of arsenic from beef, mutton,
chicken, and duck meats could be 0.038–0.833 mg, 0.305–0.783 mg,
1.80–3.83 mg, and 0.243–0.684 mg, respectively.
Fish is one of the regularly consumed foods in Bangladesh with a
consumption rate of 15–96 g/person/day (Islam et al., 2015). There-
fore, the estimated arsenic exposure to a Bangladeshi individual from
their fish diet could be between 1.36 and 50.88 mg per day (based on
the lowest and highest data reported here), which is substantially
higher than that of meats.
Arsenic exposure from drinking water is directly proportional to the
water intake and arsenic concentration in the water. The average direct
and indirect water consumption by a Bangladeshi individual between
the ages of 16–60 years is 6.1 L per day for males and 4.84 L per day for
females (Hossain et al., 2013). Considering arsenic concentrations in
drinking water of Bangladesh between 10 and 50 µg L−1 (as reported
by Chakraborti et al. (2015), the estimated daily exposure of arsenic
from drinking water varies between 61–305 µg and 48.4–242 µg for a
Bangladeshi male and female, respectively.
3.1.2. Non-dietary sources
Non-dietary sources of arsenic are diverse. One possible pathway is
the direct ingestion of contaminated soil. Surface soil is the main sink of
arsenic from different environmental sources. Worldwide, the back-
ground concentration of arsenic in uncontaminated soils typically
ranges between 4 and 10 mg kg−1 (Smedley and Kinniburgh, 2002),
while in arsenic contaminated areas (e.g. Bangladesh) it can be as high
as 81 mg kg−1 (Huq et al., 2003). During field works, arsenic con-
taminated soil particles may stick to hands and get ingested during
hand-to-mouth activities, accidental soil ingestion, or via intake of
foods (e.g. vegetables) to which contaminated soil is attached (Alam
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Ecotoxicology and Environmental Safety 150 (2018) 335–343
et al., 2003; Joseph et al., 2015a).
Soil ingestion rate by humans depends on their occupation. For
example, mean soil ingestion rate of 75 mg/day for a wilderness com-
munity (mainly involved in outdoor activities) in Canada has been es-
timated to be 200 mg/day (Doyle et al., 2012). Individuals involving in
activities with extensive soil contact such as agriculture are likely to be
exposed to much higher soil ingestion. With an estimated 35 million
workers involved in agricultural sector in Bangladesh (Joseph et al.,
2015a), it is likely that soil ingestion can be an important arsenic ex-
posure pathway for the population of the country.
Another non-dietary source of arsenic is the exposure through in-
halation. Inhalation of air containing arsenic particles or inhalation of
gaseous forms of arsenic can also be a route of arsenic exposure to
humans. In the rural areas of Bangladesh, biomass fuels provide 90% of
the energy needs with agricultural residues – 45%, woods – 35%, and
animal dung – 20% (Nath et al., 2013). Burning these biomass fuels for
cooking and inhalation of smoke by the rural population of Bangladesh
can be a potential route of arsenic exposure. Tobacco smoking can be
another arsenic exposure pathway for Bangladeshi population. Ban-
gladesh is one of the top tobacco consuming countries in the world
(Barkat et al., 2012). Tobacco leaves in branded cigarette has been
reported to contain arsenic concentrations ranging between 0.65 and
0.72 µg g−1, while a higher concentrations (2.12–2.64 µg g−1) of ar-
senic was found in non-branded cigarette and raw tobacco leaves (Arain
et al., 2009). Another study reported 0.13–0.27 µg g−1 of arsenic in
bidis (a locally produced low-price tobacco products commonly con-
sumed by low-income people of Bangladesh) and cigarette in Bangla-
desh (Lindberg et al., 2010).
3.2. Public health impacts of arsenic exposure
According to the World Health Organization (WHO) estimation,
over 200 million people worldwide are exposed to arsenic above the
WHO safety level of 10 µg L−1 in drinking water (Table 1) (WHO,
2008). In Bangladesh, between 35 and 77 million people (Table 1) has
been reported to be at risk of arsenic poisoning (Chakraborti et al.,
2015).
The International Agency for Research on Cancer (IARC) classifies
arsenic as a “Group I” carcinogen. The US Environmental Protection
Agency (US EPA) lists inorganic arsenic as a “Group A” or known car-
cinogen (Joseph et al., 2015b). Arsenic ranks the No. 1 on the US
Agency for Toxic Substances and Disease Registry (ATSDR) 2013 sub-
stance priority list (ATSDR, 2013). This ranking does not include full
consideration of total exposure of a substance from all dietary and non-
dietary sources. Therefore, human health risk of arsenic is even greater
than its top ATSDR ranking.
Table 1
Arsenic exposure concerns worldwide (reproduced from environmental health perspec-
tives, Naujokas et al., 2013).
Country Estimated exposed Arsenic concentration in drinking
population (millions)a water (μg L−1)
Argentina 2.0 < 1–7550
Bangladesh 35–77 < 10 to > 2500
Chile 0.4 600–800
China 0.5–2.0 < 50–4400
Ghana < 0.1 < 2–175
India > 1.0 < 10 to > 800
Mexico 0.4 5–43
Taiwan NA < 1 to > 3000
United States > 3.0 < 1 to > 3100
Vietnam > 3.0 < 0.1–810
Note: NA = not available; NRDC = National Resources Defense Council.
a
Estimated number of persons exposed to > 10 μg L−1 arsenic in drinking water.
M.A. Rahman et al. Ecotoxicology and Environmental Safety 150 (2018) 335–343

3.2.1. Non-carcinogenic effects Table 2

Although skin cancer has also been identified, skin disorders and Examples of health effects across multiple bodily systems in humans for arsenic exposure
(reproduced from environmental health perspectives, Naujokas et al., 2013).
keratosis are the most common external indicators of arsenic poisoning.
Chronic arsenic poisoning can cause skin lesions, restrictive pulmonary Target organs Health effects on humans
disease, peripheral vascular disease, gangrene, hypertension, non-cir-
rhotic portal fibrosis, ischemic heart disease, and diabetes mellitus Skin • Skin lesions
• Skin cancer
• Increased
(Edmunds et al., 2015; Joseph et al., 2015b). Raindrop pattern of pig-
Developmental processes infant mortality
mentation and depigmentation of skin are particularly distinct on the
• Reduced birth weight
edges and the chest. Hyperkeratosis (hardened skin) is also seen pre-
dominantly on the feet (Hong et al., 2014).
• Altered DNA methylation of tumor promoter
regions in cord blood and maternal leukocytes
The human health effects of arsenicosis are characterised by slow • Neurological impairments in children

appearance of the external and internal symptoms. The main symptom • Early-life exposure associated with increased
cancer risk as adults
of the disease is skin lesion (keratosis) that becomes visible usually
around 10 years after first exposure (Edmunds et al., 2015). Black le-
Nervous system • Impaired
adults
intellectual function in children and

sion (discoloured skin) on the feet and hand, a peripheral vascular • Impaired motor function
• Neuropathy
• Increased
disorder similar to gangrene, is another common symptom of arseni-
Respiratory system mortality from
cosis. The skin discolouration caused by arsenicosis has been commonly
• Pulmonary tuberculosis
known as “black-foot disease” that was first documented in Taiwan • Bronchiectasis
(Chen et al., 1985). • Lung cancer
Cutaneous lesion is one of the best-known clinical indices of chronic Cardiovascular system • Coronary and ischemic heart disease
• Acute myocardial infarction
arsenic exposure. This can occur within months or after several years of
• Hypertension
exposure (Das and Sengupta, 2008). Melanosis (hyperpigmentation) Liver, kidney, and • Liver cancer
and keratosis are two frequently occurring dermatological non-cancer bladder • Kidney cancer
effects of arsenicosis. Melanosis is considered to be an early symptom, • Bladder and other urinary cancers
while keratosis is a sensitive sign of more advanced stages of arseni- Immune system • Altered immune-related gene expression and
cytokine expression
cosis. Leucomelanosis (hypopigmentation) occurs less frequently than
• Inflammation
melanosis or keratosis (Naujokas et al., 2013). Numerous epidemiolo- • Increased infant morbidity from infectious diseases
gical research on skin lesions reveal that most of the individuals Endocrine system • Diabetes
drinking water having arsenic concentrations of > 100 µg L−1 have • Impaired glucose tolerance in pregnant women

skin lesions; however, occurrences of skin lesions have also been found
at arsenic concentrations of < 50 µg L−1 in drinking water. A Health
Effects of Arsenic Longitudinal Study (HEALS) showed that decreasing
the exposure of arsenic did not reduce the risk of skin lesions for up to
several years (Argos et al., 2011). Therefore, symptoms of arsenicosis
can appear even after several years of exposure, and many of the ex-
posed individuals may not develop arsenicosis symptoms but are still at
arsenic-related risks.
3.2.2. Carcinogenic effects
Arsenic is a known carcinogen. It can cause cancer in skin, lung,
bladder, liver, and kidney. Some of the most common types of skin
cancers related to chronic arsenic exposure are squamous cell carci-
noma (Bowen's disease), invasive squamous cell carcinoma, and basal
cell carcinoma (Naujokas et al., 2013). Regardless of exposure path-
ways, chronic arsenic exposure is associated with lung cancer risk.
Numerous evidences suggest that lung cancer is the most common
reason for arsenic-related mortality (IARC, 2012; Smith et al., 2009). It
is well established that individuals with drinking water containing >
100 µg L−1 arsenic are more likely to be at risk of lung cancer (Putila
and Guo, 2011).
Arsenic exposure can cause cancers in other organs of human body
as well. Studies showed that arsenic exposure from drinking water for
longer period (> 40 years) at high concentration (> 600 µg L−1) is
associated with risk of bladder cancer (Gibb et al., 2011). Risk of kidney
cancer from arsenic exposure corresponds to a dose-dependent manner
for drinking water (Naujokas et al., 2013). Several studies have sub-
stantiated association between arsenic exposure and liver cancer (such
as liver angiosarcoma) (Liaw et al., 2008).
3.2.3. Other effects
In addition to carcinogenic and non-carcinogenic health risks of
chronic arsenic exposure, arsenic-associated health problems can affect
many of the major organs and organ systems in human body (Table 2).
For example, neurological impairments such as impaired cognitive
abilities and motor functions have been reported in children and adults
after arsenic exposure (Parvez et al., 2010). Cognitive impairments in
• Disrupted thyroid hormone, retinoic acid, and
glucocorticoid receptor pathways in mice and
amphibians
children at 6 and 10 years of age (Wasserman et al., 2007) and losses of
verbal and full-scale IQ in girls (Hamadani et al., 2011) may occur due
to arsenic exposure. Significant association between arsenic exposure
from drinking water and impaired cognitive ability as well as education
(Gong et al., 2011) and link between hypertension and arsenic exposure
(Abhyankar et al., 2012) have been well documented.
Arsenic exposure may also affect human immune system including
altered immune-related gene expression and cytokine production in
lymphocytes (Morzadec et al., 2012). Human and animal studies
showed that arsenic exposure may affect multiple endocrine such as
hormone regulation via the retinoic acid, thyroid hormone, and es-
trogen receptors (Barr et al., 2009). Increased occurrence of diabetes is
also likely to be linked with arsenic exposure, particularly at high
concentration and long exposure period (> 10 years) (Del Razo et al.,
2011).
3.3. Socio-economic aspects of arsenicosis
Human health is defined not only by physical state of individuals
rather it is a state of complete physical, psychological, and social
wellbeing (Brinkel et al., 2009). From a literature search, only few
scientific and technical reports have been found that addressed socio-
economic implications and consequences of arsenic exposure to Ban-
gladeshi populations. Evidence from literature review suggests that
instead of being supported and consoled by their families and com-
munities, sufferers from arsenicosis are avoided and neglected to the
point of becoming social misfits or outcasts (Hassan et al., 2005). Al-
though arsenicosis patients may not feel ill or look ill during the early
stage of arsenicosis, they are treated as ‘dangerous people’ and stripped
of their social status. The arsenicosis patients may face many economic
problems including financial losses, decreased work efficiency, and
inability to get suitable jobs due to discrimination (Ahmad et al., 2007).
Arsenicosis patients face ostracism. A significant number of

340
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arsenicosis patients facing ostracism have been reported in Bangladesh
(Ahmad et al., 2007). At the early stage of arsenicosis, patients do not
disclose symptoms of the disease to avoid ostracism. Patients in rural
areas are discouraged to appear in public and family members incline to
avoid direct contact with the patients. School-age children having
visible symptoms of arsenicosis are discouraged to attend schools and
their friends and classmates stay away from them. In many cases, ar-
senic victim adults are banded from attending social events (Alam et al.,
2002). In many cases, husbands left wives or re-married and wives left
their husbands temporarily due to fear of being infected by arsenicosis
(Chowdhury et al., 2006). Arsenic victim families are refrained from
water collection from their neighbour's tube wells and ponds, and even
people refrain from making new relationship with arsenic victim fa-
milies (Chowdhury et al., 2006).
As female are the most vulnerable group in the society, arsenicosis
female patients in Bangladesh are the worst victims of ostracism. For
example, female patients having arsenicosis symptoms may be ne-
glected by their husbands (Hassan et al., 2005). There are some in-
stances where wives were divorced or separated or sent back to their
parents’ home because of their arsenicosis disease (Argos et al., 2007).
In a study, out of 25 individuals having arsenicosis, 8% female patients
said that their husband had abandoned them because of their arseni-
cosis disease, 19 arsenicosis patients (76%) said they were hated by
others, and 6 patients (24%) said that they were avoided by their
friends and colleagues (Ahmad et al., 2007). Another study found that 3
women (out of 37 affected women) were forced to go back to their
parents and 2 had been divorced because of their arsenicosis illness
(Hassan et al., 2005).
Arsenicosis patients face problems in relationship within the family
and in the community. Available evidence suggests that in Bangladesh
arsenicosis patients become the burden to the family and the society
(Ahmad et al., 2007; Argos et al., 2007; Bearak, 1998; Chowdhury
et al., 2006; Hadi and Parveen, 2004; Hanchett, 2006; Mahmood and
Halder, 2011). The problem can be classified into three groups: diffi-
culty in getting married, conflicts within the family, and difficulties in
socialisation.
Difficulties in getting married are manifested in various forms. For
example, arsenicosis male patients mainly face economic problems,
while the female patients face social problems mostly related to pre- as
well as post-marital relationships. People become reluctant to establish
marital relationship with arsenic victim families. Arsenic victim young
men and women are advised by the their family to remain unmarried,
which results in significant social instability of rural areas of the
country (Chowdhury et al., 2006).
In rural areas of Bangladesh, the adult females are the most vul-
nerable to disease due to their poor health condition. When a husband
sees arsenicosis symptoms on his wife's body, he refuses to stay to-
gether. The husband realises that it too risky to continue marital re-
lationship with his wife and seeks divorce. Sometimes, the husband
may send her back to her parents for treatment (Alam et al., 2002;
Chowdhury et al., 2006).
In a rural setup in Bangladesh, where divorce is often socially
abused even under normal circumstances, divorce for arsenicosis is a
social burden. The divorced woman has no place in the society.
Therefore, it is a big problem for the parents to get their daughters
having arsenicosis symptoms married that make their life miserable
(Chowdhury et al., 2006).
Problems within family relationships are characterised by the ten-
dency to avoid arsenic victims. Parents hesitate to stay closer to their
children and children do not like to come close to their parents.
Husbands stay away of their wives having arsenicosis disease (Hassan
et al., 2005). It is a terrible situation in a family atmosphere in Ban-
gladesh. A 17-year old girl, who developed symptoms of arsenicosis
(palms and skin lesions) in her whole body, said that her parents were
rude to her, and she felt that she was a burden to her parents (Hassan
et al., 2005). A 26-year old man having arsenicosis was indirectly
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Ecotoxicology and Environmental Safety 150 (2018) 335–343
neglected and isolated by his family members (Hassan et al., 2005).
Women are the worst victims of arsenicosis. Like many other
household responsibilities such as cooking, feeding children and
cleaning, women play a key role in securing arsenic-free drinking water
for the family members. Sometimes, the women have to walk up to few
kilometres to get arsenic-free water, which becomes a burden with
additional responsibilities and they have to compromise with cultural
and religious ideology (Chowdhury et al., 2006). The visible arsenicosis
symptoms such as spotted melanosis, keratosis and ulcer keratosis make
the adult unmarried women victims physically weaker and less ap-
pealing to the men. Therefore, it would be extremely difficult for par-
ents of a young girl having visible arsenicosis symptoms to find a man
for her without offering a huge dowry. Dowry is already an important
social problem in the Bangladesh, and this problem would be further
compounded by arsenicosis.
Due to the masculine nature of society and socio-cultural position of
women in society in Bangladesh, unmarried and divorced women
having arsenicosis live inhumanely. They are the most negligible among
all victims of the disease. A study conducted in Samta village of Jessore,
Rajarampur of Chapainawabgang, and Courtpara of Kushtia in
Bangladesh, where arsenic contamination is very high, involving 55
female victims at the verse of social violence revealed that a significant
portion of the women with arsenicosis disease were subject to domestic
violence such as dowry (40%), divorce (17%), separation (17%), de-
sertion (11%), physical torture (9%) and polygamy (7%) (Chowdhury
et al., 2006).
Difficulties in socialisation arise due to ignorance and poor literacy
level, especially in rural areas. Superstitions, prejudices and fairy tales
are built surrounding the arsenic victims. People do not want to make
close relationship with the arsenic victims, neglect them and become
scared of them because of such superstition (Chowdhury et al., 2006).
Due to lack of proper knowledge about arsenicosis, some people think
of it as an act of devil or evil spirits or impure air, and keep themselves
and their family members away of the patients. Because of such su-
perstitions and prejudices, most of the patients did not receive any
treatment, and have been passing miserable lives (Chowdhury et al.,
2006). Arsenic victim school children are also faced prejudice. Friends
of arsenic victim school children keep themselves away of them, do not
like to share books and pencils, and do not let them taking parts in
sports. Even, teachers restrict their access to school (Hassan et al.,
2005).
Arsenicosis also causes extreme instability in social life. Case studies
showed that arsenicosis patients received social injustice and the neg-
ligence by their local leaders. In some cases, the local leaders are not
cooperative to the arsenic victims in getting financial support from the
local government and treatment from appropriate medical practitioner
(Hassan et al., 2005).
In a socio-economic rural setup in Bangladesh, the male is generally
the sole earning person in a family. Socio-economic analysis of arsenic
contamination issue in Bangladesh showed a strong link between pov-
erty and arsenicosis (Argos et al., 2007; Brinkel et al., 2009; Hassan
et al., 2005). Many of the rural poor people are engaged in either
agriculture or daily labouring. If the employers identify the employees
as arsenicosis patient, the employers do not hire them. Even after ap-
pointment, if the employers discover their sickness, the arsenic victim
workers lose their jobs immediately (Chowdhury et al., 2006).
Different types of socio-economic consequences of arsenicosis have
been identified in Bangladesh. For example, arsenicosis patients face
difficulties in getting job due to their disease (Hassan et al., 2005).
Ahmad et al. (2007) surveyed the socio-economic problems of arseni-
cosis in arsenic affected areas of Bangladesh. They found that 58.6% out
of 140 respondents having arsenicosis patient in their family experi-
enced economic problems because of arsenicosis. The problems they
identified for the arsenic victims included decreased work efficiency,
financial difficulties due to lose of their work, and inability to get a job.
The early symptoms of arsenicosis become more pronounced day by
M.A. Rahman et al.
day depending on patient's arsenic exposure rate and the availability of
treatment.
3.4. Socio-economic hazards of arsenicosis
A social hazard of a particular event is characterised by the nature
and magnitude of damage the event poses to people's social norms and
social structure. Several studies reveal that arsenicosis has created ex-
tensive social and economic problems for the victims and their families
in affected areas including social degradation, social injustice, and so-
cial isolation. Therefore, arsenicosis has been considered not only as a
health problem, but also as a major socioeconomic hazard of
Bangladesh as this health problem represents a challenge to the victims
and their families’ social status, lifestyle, and financial condition.
Studies identified a strong relationship between poverty and ar-
senicosis disease. Compared to higher income group, arsenicosis pa-
tients of lower income group are at risks of social as well as economic
risk in Bangladesh (Ahmad et al., 2007; Mahmood and Halder, 2011).
This is likely due to the poor health condition of the patients of lower
income group, and hardship in accessing safe drinking water, and dif-
ficulties in getting proper treatment of the disease as they cannot afford
the costly medicine. Because of financial problems, many arsenicosis
patients cannot get any treatment in Bangladesh (Chowdhury et al.,
2006). The untreated victims become physically weak day by day, and
they become incapable of doing hard work.
In some cases, arsenicosis patients lead miserable lives, and the
patients attempt to commit suicide to end up the unbearable misery. In
rural Bangladesh, some local religious cleric refuse to bury with Muslim
rites when an arsenicosis patient die (Hassan et al., 2005).
Social conflicts over arsenic contamination in drinking water un-
dermine the social harmony, network relationship, and isolation as
arsenicosis victims are often wrongly identified as leprosy patients
(Brinkel et al., 2009). Arsenicosis also hampers socialisation by social
stigmatization and discrimination. For example, arsenic victims are
often ostracized and barred from social functions. Children of arsenic
victims are not allowed to attend social and religious gatherings as well
as deprived of taking arsenic-free water from a neighbour's tube well
(Keya, 2004). Arsenicosis victims are not allowed to take bath in the
village ponds in a fear that they may contaminate the ponds’ water.
Many of the unaffected people are rude and unfriendly to the arsenic
victims, and think that the patients should stay in their home or leave
the village (Hassan et al., 2005).
Social instability has become a serious social problem in arsenic
affected areas of Bangladesh. The arsenic victims are facing isolation
within their families as well as in the society. Unemployment, domestic
violence, discrimination in workplace, isolation, physical torture, di-
vorce, and separation are common social problems that the arsenicosis
victims are facing. It has been evidenced from several studies that social
hazard faced by the arsenic-affected people, driven by loneliness, social
injustice, frustration, damage to social bonds results in social instability
in arsenic affected areas of Bangladesh (Argos et al., 2007; Hassan et al.,
2005).
4. Conclusion
With the identification of the problem in Bangladesh in early 90's,
arsenic contamination in drinking water was identified to be as a sig-
nificant human health issue of Bangladesh. The Government of
Bangladesh raised this issue to the international forums to resolve the
problem. In response, many international organizations and research
institutes funded millions of dollars and worked together with the
Government and Non-Government Organizations (NGOs) of the country
to investigate the severity of the problem and to find the best way to
resolve this issue. Over the last 20-years, several hundreds of research
articles have reported in-depth scenarios of arsenic problems in
Bangladesh and the national and international experts have made their
342
Ecotoxicology and Environmental Safety 150 (2018) 335–343
thoughtful recommendations to the respective authorities of the
country on the mitigation of arsenic contaminated drinking water.
However, the implementations of those recommendations are not sa-
tisfactory.
During the last two decades, national/international research groups
working on arsenic contamination in Bangladesh with a focus on social,
environmental, and human health issues reveal that arsenicosis patients
become a serious burden to the family and the society. As hundreds of
thousands of people have been affected by arsenic contamination in
Bangladesh, health complications related to arsenicosis will be an extra
burden on the already hard-pressed health services of the country.
Evidences from literature review reveal that the poorest fraction of the
society faces the worst arsenic contamination-related problems, parti-
cularly those who are already undernourished. Severe social and eco-
nomic hazards have emerged in the arsenic affected areas of the
country, and this problem has triggered several unexpected social
problems that were still not fully recognized. In addition to health
problems, arsenic poisoning has created many socio-economic pro-
blems. Perhaps the worst social disaster is yet to come; however, this
can be avoided if appropriate strategies are undertaken by improving
the quality of life of the affected population. For example –
i) Organize preventive campaign based on a holistic approach among
the people of arsenic affected areas to aware them about the risk of
arsenic to human health.
ii) Provide a cheap and cost-effective arsenic mitigation technology to
the affected population to reduce arsenic in drinking water.
iii) Provide affordable and/or subsidized treatment of arsenicosis to
the patients.
iv) Increase awareness of arsenic contamination, health risk and socio-
economic consequences of arsenicosis among the affected popula-
tion.
v) Organize community activities including group discussion and
community education regarding arsenicosis to reduce social dis-
crimination of the patients.
vi) Effective efforts by the local government to provide safe drinking
water to the population of arsenic affected areas.
vii) Contact with social services and sanitary authorities to reduce the
level of exclusion of sick individuals from society and others.
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