The 2002 survey revealed that awareness of arsenic had increased since 2000 (). In 2000, 32.2% of the male and 22.3% of the female respondents were aware of arsenic; in 2002, 63.0% of the males and 59.9% of the females were aware of arsenic in water. The increase in awareness among women is particularly significant given that they are the principal users of water, and their cooperation is essential to any health strategy concerned with the appropriate use of water.
Impact of information campaign (percentage of respondents)
Both male and female respondents with a formal education were much more likely to be aware of arsenicosis, although the educational differential had narrowed somewhat by 2002 ().
Knowledge of arsenicosis by education (percentages)
The increase in awareness among women and less-educated respondents largely reflected an enhanced role of NGOs in raising awareness and an increase in community discussions with friends and neighbours ().
Sources of arsenicosis knowledge (percentages of those who have heard of arsenic)*
Most respondents did not know the health effects of arsenic, and only 12.9% were aware that arsenic could result in death ().
Worst-perceived outcome of contaminated water (percentages)
A key component in the Government's response to arsenic was testing wells. The surveys indicated that, while most wells remained untested, there had been a marked improvement from 5.7% tested in 2000 to 16.3% in 2002 (). This is well below the 50% reported for affected areas (24
), but our survey included substantial areas outside the most affected areas. Nevertheless, even when taking this into account, there remained a worrying discrepancy.
Wells tested for arsenic contamination by division (percentages)
The 2002 survey identified that pumps used by 34.2% of the households interviewed were painted red, indicating that these exceeded the acceptable levels of arsenic, 27.3% were painted green to indicate these were acceptable, while 38.7% of the households had wells that had been left unpainted. It was unclear why these wells had not been painted.
Despite a great increase in awareness of arsenic, there had been only a moderate behavioural response towards the use of alternative water sources. In areas of high contamination of arsenic, the BAMWSP promoted the use of alternatives to tubewell water, such as sanitary dugwells, filtered pond-water, and deep tubewells, or, where these are not available, water filtered to remove arsenic. Deep tubewells are believed to be less dangerous than ordinary or shallow tubewells because they draw water from a deeper aquifer, which is usually much less contaminated by arsenic, although the required precise depth varies in the local aquifers (25
The data indicate that the use of tubewell water has not declined. In 2000, 87.2% of the respondents used shallow tubewells and 6.9% deep tubewells—the distinction between shallow and deep tubewells was self-defined and hence is only approximate. In 2002, 88.5% were using shallow tubewells and 7.4% deep tubewells ().
Source of drinking-water (percentages)
The proportion of rural households not using either type of tubewell had declined from 5.9% to 4.1%. These findings are not surprising; these reflect a desire for households who can afford it to have their own source of water. Realistically, only inexpensive shallow tubewells provide such an option. Importantly, in contrast to the early 1970s when tubewells were promoted and paid for by the Government and international agencies, most wells are now privately owned by the household itself. Van Geen et al.
have estimated that there are now up to 10 million tubewells, of which more than three-quarters are privately owned; in their own research area, 94% of tubewells were privately owned (25
There is more to the desire to have one's own tubewell than simply the wish for a new prestige item in a country where few obvious consumer items can be afforded. Many continue to associate tubewell water with safe water, at least with regard to diarrhoeal disease, while women particularly want a water source that is convenient, given that collection of water can cut a great deal of their time, and one which they can control by having a tubewell installed in their own yard (20
Disputes over access to water are a source of village conflict. When households that had access to their own wells were asked in the 2002 survey what their main reason was for installing tubewells, there was a remarkable contrast between the answers of male and female respondents, reflecting different gender perspectives and experience on water ().
Major reasons for installing a tubewell (households who have installed their own tubewells)
Men were much more likely to give ‘safe drinking-water’ as their main reason, while women were equally likely to list ‘safe water’, ‘convenience’, and ‘the ability to control one's own water’. The men's answers appear to reflect past information campaigns, while women's answers reflect their greater role in water management and concern about practical issues that directly affect them. The implication of these responses is that if households need to be encouraged to switch away from using tubewell water, the message will need to be convincing, especially to women who are usually most concerned with water management.
An alternative to moving away from using tubewell water is for households to filter tubewell water to remove arsenic. This is potentially cheaper and more convenient than abandoning tubewells but also requires careful maintenance of the filter system, training, and at least some support in the initial stages. There is also a question regarding the long-term effectiveness of available filtering systems and the difficulties in using such systems for households (19
). Perhaps for this reason, very few (0.6%) respondents filtered water for removing arsenic ().
Overall any response to arsenic (percentages)
When asked why they did not treat their water, the majority of people in the 2002 survey stated that they did not know how to, while smaller proportions did not believe that their wells contained arsenic or they did not perceive arsenic to be a problem ().
Main reasons for not treating water in 2002 (percentages)
The main behavioural response to arsenic identified was changing the water source. Nearly 90% of those who changed did so from one tubewell water source to another. This may be the most appropriate response. Considerable variability has been reported in levels of arsenic between neighbouring wells (17
). Provided that not too great a distance is involved, this solution offers lower arsenic intakes while retaining the advantages of tubewells in providing water that is free of microbial contamination. A number of researchers have recommended this approach (21
). Despite its attractions, the approach has not generally been favoured as there continues to be concerns about the reliability of testing and the fact that many wells falling below the Government arsenic standard contain some arsenic.
Switching from wells was the major response to arsenic recorded in the national survey. Households were asked whether they had previously used another tubewell. Nearly four-fifths (77.9%) had, but in only 11.1% of these households had those wells been tested. Where wells had been tested, households whose wells had been painted red were more likely to have shifted to other sources of water. Of the households whose previous wells had been tested, 57.3% had been painted red, 27.1% had not been painted, and 15.6% had been painted green. In comparison, the equivalent figures for current wells of households were: 34.5% wells were painted red, 27.5% wells painted green, and 37.4% wells not painted. Nevertheless, as these figures indicate, many households whose wells had been painted red continued to use them: 32.3% of all households whose current or previous wells had been tested for arsenic were currently drinking water from wells marked red. This means that 5.7% of the total population drank such water.
A prerequisite for a better response is the testing of more wells. While testing has increased, most wells remain untested. For people to respond adequately, they need to know whether their existing well is safe or not, and, if they prefer to use an alternative well, whether this will be safe. Although Cheng et al.
have found only limited variability in concentration of arsenic over time (30
), the process may also require re-testing of wells as it has been argued that levels of arsenic in wells may change.
However, the largest single factor preventing a behavioural response to arsenic is probably a lack of conviction that it is necessary or that it is in the interests of households to change their current water-use behaviour. While the respondents had heard of arsenic, the survey data did not suggest that they regarded it as an urgent health concern. Only 12.9% reported that arsenic could lead to death. Very few could identify people who were affected by arsenic, interests of households to change their current water-use behaviour. While the respondents had heard of arsenic, the survey data did not suggest that they regarded it as an urgent health concern. Only 12.9% reported that arsenic could lead to death. Very few could identify people who were affected by arsenic, and even fewer believed that a household member might be suffering from it.
The conditions to which arsenic poisoning may contribute, including internal cancers and cardiovascular diseases, also have other causes, and especially lay people may not believe that they are connected to arsenic. A long-latency period, in which arsenic-induced conditions may not manifest for decades, contributes to this confusion. It is partly for this reason that it took so long to realize the dangers of arsenic. The most obvious condition caused by arsenic is arsenicosis, which involves skin lesions that may, in due course, lead to skin cancer. There has been considerable debate about defining a diagnosis for arsenicosis and evaluating its link to more life-threatening conditions (31
When asked whether anyone in their households had a condition caused by arsenic, only three respondents in 2002 said there was someone. Given the difficulty of defining arsenicosis, this number is not surprising, but it does emphasize the problem in convincing the average person that arsenic is a major health issue.