Project

Alright, I have to take this opportunity to share what my mother and I did last night--we've managed to stick with this tradition for about fifteen years now, and next December it will be sorely missed. In any event, I spent most of the day baking, and most of the evening decorating, and here are a few examples of the finished products. Granted, it's really more an exhibit of my mom's artistry than my own, but I'm quite proud of them nonetheless...

Mail

Just in case anybody wants to send me letters (or small packages not exceeding 2 lbs.), you can use the "diplomatic pouch"--it'll save you the international postage :)

Alicia Cooper, Fulbright
AmEmbassy Dhaka
Department of State
Washington, DC 20521-6120

And I will be mailing postcards--that almost goes without saying--so if I don't have your address, please pass it along!

Happy Holidays!

Nine-and-a-half feet of coniferous joy.

Happy Holidays to all!

Input Needed!

My impending departure (11 days!) has forced me to start thinking about packing. The prospect is a bit daunting, to say the least, so I've decided to ease myself into it by considering what sources of entertainment I can afford to pack. I'm trying to settle on two DVDs and one fun book (along with a few more serious selections).

So, my question:

If you could only have one fun book for a year, which would you choose? (Optional: Why?)

Snow Day?

When I went outside to take these pictures, I heard some very happy shouts and laughs coming from the house on the hill--I have a hunch that Hartland Elementary had its first snow day of the season.

I used today's snow as an excuse to have a giant cup of hot chocolate.

It's Official

I purchased my plane ticket yesterday, so I guess I'm actually going!

Boston --> London --> Bahrain --> Dhaka

And special thanks to my travel agent Gretchen, who is awesome.

Snow!

It has begun!

Maps

Last night I attended the opening program for Dartmouth's Great Issues in Medicine and Global Health Symposium. This year, the theme is poverty, and as such, the evening's discussion was entitled "Global Health Equity". Speakers included Dr. John Butterly, the executive medical director of DHMC and professor at both the college and the medical school; Tom Ketteridge, the managing director of the Upper Valley Haven; and Dr. Paul Farmer. (As one of Paul Farmer's "groupies", I had little choice but to attend...)

Topics of discussion ranged from rural poverty and homelessness in this area to the implementation of comprehensive care models across the globe. And while I don't plan on going into exhaustive detail , I did think this would be a good place to share one aspect in particular. Dr. Farmer began his discussion by showing two maps from Worldmapper. I took a look at the site today and found an index of over 350 maps--I'll put four here, but I'd encourage everyone to check it out for themselves.

Map 1: Land Area. The "normal" view.

Map 219: Practicing Physicians

Map 213: Public Health Spending

Map 186: Poor (Unsafe) Water

--

This last map seemed most relevant for my (hopefully) overarching theme. Bangladesh is visible here--dwarfed in comparison to neighbor India, but larger than both the U.S. and Western Europe. Further, this figure assumes groundwater sources are safe. When such "safe" water sources are also unsafe, what alternatives remain?

The Role of Anthropology: Part IV

While many research initiatives have focused on potential methods to curb the spread of arsenicosis, there have been only a few promising long-term solutions (Anstiss et al., 2001). Many scholars believe that promoting the use of safe community wells would be the most sustainable initiative. Furthermore, because a well’s operation is of community concern, a given population will unite in supporting arsenic mitigation efforts. Such projects have had more long-lasting success than initiatives to make arsenic-contaminated or pathogen-containing water potable—these treatment operations are costly and time-consuming, and only occasionally receive the full attention and support of an affected community (Jakariya et al., 2005).

Some of the interventions piloted by non-governmental development organizations have shown that the mere presence of a water treatment plant in a village serves to mobilize a community (Hadi, 2003; Hoque et al., 2004). This causes arsenicosis to be brought to the forefront of public attention—as the topic becomes familiar, and a point of discussion, the popular desire for safe water sources is increased. Moreover, individuals are more willing to become involved in water-testing and monitoring efforts (Jakariya et al., 2005). Such community mobilization has been brought about by the work of NGO-affiliated community health educators, who travel to each household in a village and instruct residents about the dangers, symptoms, and safety measures associated with arsenicosis.

Community involvement would seem to be widely effective, thus it is of critical significance to continually seek ways to actively engage affected and threatened communities while designing arsenic mitigation programs. This matter is complicated by the findings of some studies. Based on the extent of willingness to pay a portion of household income for safe water, some researchers have concluded that rural inhabitants of Bangladesh place a low value on safe water (Ahmad, Goldar, & Misra, 2005). A different exploratory approach might employ the participatory action (PAR) model, such that community members would have more than a passive role in securing safe water. This model emphasizes the production of knowledge to foster future action, taking local opinions and concerns into consideration (Patten, Mitton, & Donaldson, 2006). This model has been successfully employed in numerous disciplines to accomplish a wide variety of ends, yet has not yet been fully utilized within the context of Bangladesh’s groundwater contamination.

Additionally, future studies might consider utilizing the ecohealth system. The ecohealth system integrates ecological and health concepts to promote responsible stewardship of the environment, while consequently fostering changes in local health conditions (Yacoob, Hetzler, & Langer, 2004). Pilot programs in Bangladesh have shown this to be a promising technique for involving the community by means of educating and providing the needed resources for village-based operation and management of safe-water utilities (Yacoob et al., 2004).


NOTE: If you would like full bibliographic information for any of the above citations, please let me know.

Fight World Hunger

...and improve your vocabulary at the same time!

http://www.freerice.com/index.php

It's completely addictive, and for a good cause. Win-win!

Keeping Busy

Also, I made cookies...

The Role of Anthropology: Part III

Wells are used almost exclusively by women in Bangladeshi communities (Ohtsuka, Sudo, Sekiyama, Watanabe, Inaoka, & Kadono, 2003). The water gathered on a daily basis is used domestically for cleaning, personal hygiene, cooking, and consumption. Consequently, education of women may well prove to be the most successful approach in disseminating information about arsenicosis. Female community health workers have had success in educating at the household-level (Hadi, 2003); future studies might focus on the transmission of such information among families and neighbors and within a village.

Several investigations have focused on the possibility of well-sharing as a viable mechanism for delivering safe water to a large number of individuals. While many tube wells in rural Bangladesh are privately owned, an estimated 80% of these wells contain dangerously contaminated water, and thus a large portion of the Bangladeshi population is at risk for arsenic exposure and, ultimately, arsenicosis (Chowdhury, Rahman, Mondal, Paul, Lodh, Biswas et al., 2001). Initiatives that have installed community wells have found that a single tube well can provide enough water to sustain approximately 500 people (van Geen, Ahmed, Seddique, & Shamsudduha, 2003). Moreover, such community-wide well-sharing efforts have proven successful, thus, in theory, well-sharing among non-kin and non-neighbor groups is a promising possibility in some regions (van Geen, Ahsan, Horneman, Dhar, Zheng, Hussain et al., 2002). Others believe that well-switching behavior will be a viable option for some immediately, but that others will be slower to adopt the practice (McLellan, 2002).

Very little has been written thus far on the nuances of well-usage—this may be because of a high degree of variability in patterns from one village to the next. If broad-based trends do indeed exist, however, an understanding thereof would prove crucial in further discussions of arsenicosis, and must therefore be examined presently. Community dynamics may dictate which tubewells are accessible to whom. If culturally-specific complexities are at the root of well-use and –switching, ethnographic analysis could help to determine the most locally relevant methods for encouraging safe water access.

NOTE: If you would like full bibliographic information for any of the above citations, please let me know.

Foliage

Nothing new to mention here, really, so I figured I'd share with my hordes of loyal readers some of the dazzling foliage I've been enjoying lately:

Status Update

So now that I've managed to bore you with several technical posts, I figured I'd fill you in on my latest trip-prep developments.

I have officially been granted health clearance, and I've also been fully immunized against a whole host of diseases. I've been given a prescription for malaria medication--Mefloquine--that can allegedly cause vivid dreams. Mine are pretty vivid at present, so any amplification could be pretty interesting. I've also gotten my visa, and I'm buying my plane ticket this week. A bit more paperwork to follow, and I'll be good to go!

Otherwise, I've been enjoying Vermont. I'm using the 'downtime' to read--both for fun to keep up with new developments in arsenic-related research--and to relish my last days of rural solitude before moving to the most densely populated country in the world. Not a whole lot else to report, so I'll call it quits for now.

And for the sake of adding a visual element to this page, some pictures of fall in Vermont:

The Role of Anthropology: Part II

According to recent studies, the high degree of variability of arsenicosis symptoms elicits a comparably wide variety of responses in terms of treatment-seeking (Ahmed, Adams, Chowdhury, & Bhuiya, 2003; Ahmed, Petzold, Kabir, & Tomson, 2006; Edgeworth & Collins, 2006). Many of the symptoms characteristic of initial phase arsenicosis are shared with other maladies—thus, internal inflammation caused by arsenic exposure can be confused with other gastrointestinal disorders; arsenicosis-related anemia and fatigue are attributed to other common maladies. Such ailments go untreated, or they are addressed by home-treatment (Ahmed et al., 2003).

The most visible—and readily recognizable—symptoms (keratosis, melanosis, hyperpigmentation, etc.) are manifested on the hands, feet, and trunk. As noted above, many reports have indicated that such symptoms are often believed to be caused by leprosy, thus individuals exhibiting ulcerations on hands and feet are highly stigmatized. According to surveys in affected areas, these symptoms are occasionally treated by medical specialists (Paul, 2006). However, the majority of affected individuals are unaware of arsenicosis’ life-threatening potential. Consequently, few are prompted to seek health care, allowing the disease to progress to the advanced phase.

Paul & Tinnon Brock (2006) have found that, in the instances of recognized arsenic poisoning, treatment delay is most strongly influenced by three factors: 1. A tendency of waiting to see if symptoms will go away, 2. A feeling of embarrassment (or feeling burdensome) in asking for assistance, and 3. A failure to recognize the importance of the symptoms. In addition to these, socio-economic and demographic dynamics have also served to prevent and/or promote health-seeking behavior (gender, age, occupation, years of education, availability of financial resources), but reportedly to a lesser degree (Ahmed et al., 2000).

While some investigations have begun to explore the complexities of health-seeking behavior (HSB), there remains a great deal of room for expansion. The two theoretical models of health-seeking behavior could be employed simultaneously, shedding light on both the behavioral stages leading to pro-health activity (the ‘pathways model’), and the external factors that influence an individual’s health choices (the ‘determinants model’) (MacKian, Bedri, & Lovel, 2004).

It will be of further importance to examine what types of home- and alternative-treatments are being employed against arsenicosis symptoms, particularly when they are not immediately assumed to be the symptoms of arsenic poisoning. In understanding the existing systems of ethnomedicine in Bangladesh, for instance, it will be possible to assess the role of traditional practitioners in offering care for arsenicosis symptoms. Similar studies have been conducted in other parts of the world, and there have been marked successes in treatment by local health-care workers who have been trained to offer disease-specific care, either in the stead of or in conjunction with traditional methods (Amarasiri de Silva, Wijekoon, Hornik, & Martines, 2001; Marsh, Mutemi, Muturi, Haaland, Watkins, Otieno et al., 1999).


NOTE: If you would like full bibliographic information for any of the above citations, please let me know.

The Role of Anthropology: Part I

Various modes of education have been employed in recent efforts to raise awareness about the dangers of arsenic poisoning. Door-to-door information campaigns have been very successful in fostering behavioral change in pilot studies (Madajewicz, Pfaff, van Geen, Graziano, Hussain, Momotaj et al., 2007; Opar et al., 2006). More broad-based media operations have been shown to elicit a similar increase in popular knowledge, yet are less likely to result in community-initiated well testing (Madajewicz et al., 2007). Several investigations have shown that sensationalization of the problem elicits the most powerful responses from community members. “Drinking arsenic-contaminated water is like drinking poison” is a slogan that prompted a widespread demand for safe water in affected communities, particularly from concerned parents (Hadi, 2003). In communities where there have been limited education campaigns, however, the gravity of the situation is not widely understood, and thus change has been slower to reach these areas (Caldwell, Smith, Caldwell, & Mitra, 2005; Ushijima, Inaoka, Kadono, Murayama, Nagono, Nakamura et al., 2001).

The education of rural inhabitants is of crucial importance in curbing the spread of arsenicosis, yet a more concrete mode of information transmission must be developed in order to reach all of the individuals at risk (Rahman, Sengupta, Ahamed, Chowdhury, Lodh, Hossain et al., 2005). A theoretical framework of risk communication has previously been employed in relation to other public health crises, and is an area that could well be explored further with respect to the epidemic of arsenicosis (Driedger & Eyles, 2003). For instance, is risk better understood on the large scale (macro) in terms of statistics, or on a smaller scale (micro) that emphasizes the disease burden felt by individuals/ community groups? Studies have also examined the use of a common sense model (CSM) in risk assessment (Severtson, Baumann, & Brown, 2006). To what degree is common sense applicable in the context of rural Bangladesh?

Education initiatives enable individuals living in affected areas to list—and use—sources of safe water, and they have begun to accurately associate symptoms such as melanosis and keratosis with arsenic poisoning instead of leprosy (Caldwell et al., 2005). Despite these advances, arsenicosis is still widely believed to be a contagious condition, ultimately perpetuating the associated stigma. A study of stigma toward leprosy victims in Bangladesh indicated a lesser quality of life and a poorer mental health status in patients than in the general populous (Tsutsumi, Izutsu, Islam, Maksuda, Kato, & Wakai, 2007). According to stigma theory, being marginalized from a group causes one to feel reduced to only part of a person, or to feel discarded from the remainder of society (Major & O'Brien, 2005). A parallel study could be conducted with sufferers of arsenic poisoning, potentially shedding light on the interaction of victims within their villages and on the changing perceptions of arsenic as popular knowledge is increased.


NOTE: If you would like full bibliographic information for any of the above citations, please let me know.

Take My Handkerchief

Bengali lessons are coming along slowly. I've completed about 10 units, and have gotten comfortable reading and writing a little more than half of the letters. However, the emphasis isn't on building vocab just yet, so the only things that I can consistently remember how to say are:

Amar nam Alicia. (My name is Alicia.)

Aam anun. (Bring [some] mangoes.)

and

Amar rumal nin. (Take my handkerchief.)

Useful phrases--these will make for some interesting, albeit brief, conversations...

Previous Research Foci

Thus far, arsenic research has had three primary focal points: geological, engineering, and biomedical. Geological research has placed emphasis on monitoring arsenic levels in the groundwater, and determining the geological sources of the Bangladeshi groundwater contamination. Arsenic present in the alluvial Ganges aquifers originates in Himalayan catchments (Hossain, Bagtzoglou, Nahar, & Hossain, 2006). Dissolved arsenic is present most prominently at shallow levels (<150 m), and tend to be associated with Middle Holocene aquifers (Shamsudduha & Uddin, 2006). According to Hossain et al. (2006), spatial patterns of arsenic contamination exist in rural areas. In light of this information, it has been suggested that priority areas be established for water testing and remedial action. Other studies indicated an inverse relationship between topographical level and groundwater arsenic concentrations (Shamsudduha & Uddin, 2006). Researchers have also noted seasonal patterns of arsenic concentration fluctuation in agricultural soils. There is a noted increase of soil-arsenic content after irrigation of crops in the drier growing seasons, followed by a decline brought about by the wet season (Harvey, Swartz, Badruzzaman, Keon-Blute, Yu, Ali et al., 2005; Saha & Ali, 2007). In this manner, accumulation of arsenic in topsoil is found to be counteracted by natural geological processes.

Engineering efforts have emphasized the development of safe-water solutions, advocating the installation of deeper wells, the treatment of standing water sources, and the harvesting of rain water. It was found that when arsenic-removal techniques were implemented, disposal of arsenic waste was an issue of concern—if not handled properly, such arsenic could ultimately return to the local groundwater systems (Jakariya, Rahman, Chowdhury, Rahman, Yunus, Bhiuya et al., 2005). Other studies have reported the successful establishment of water renewal/ recycling centers that serve to treat contaminated water by means of ferric oxyhydroxide adsorption, and to store wastes safely (Anstiss, Ahmed, Islam, Khan, & Arewgoda, 2001; Mohan & Pittman, 2007). Pilot studies in other areas have led some researchers to believe the most cost-effective and community-friendly option would be the installation of cluster-based piped water systems (Hoque, Hoque, Ahmed, Islam, Azad, Ali et al., 2004).

Biomedical research has offered discussions of the effects of arsenic on the body and the potential for treatment alternatives. Blood arsenic content has recently been identified as a reliable biomarker of arsenic exposure (in addition to urine, hair, and nail arsenic content) and risk of skin lesion development (Ahamed, Sengupta, Mukherjee, Hossain, Das, Nayak et al., 2006; Hall, Chen, Ahsan, Slavkovich, van Geen, Parvez et al., 2006). Arsenic exposure has been found to elicit chromosomal aberrations (CA) and decreased chromosomal repair, both contributing to its carcinogenic effects (Andrew, Burgess, Meza, Demidenko, Waugh, Hamilton et al., 2006; Mahata, Basu, Ghoshal, Sarkar, Roy, Poddar et al., 2003). Other investigations have shown arsenic to have a diabetogenic effect (Rahman, Tondel, Ahmad, & Axelson, 1998; Tseng, 2004). Arsenic has also been found to disrupt several types of hormone receptors, enabling it to affect multiple body systems (McDavid & Hawkins, 2007).

Considerable research has been conducted to examine the relationship between arsenicosis and nutrition. Early studies noted a correlation between poor nutritional status and arsenic exposure, yet did not explain particular causal relationships (Milton et al., 2004). A later study suggested that arsenic exposure does, in fact, result in poorer nutritional status, especially in children (Minamoto, Mascie-Taylor, Moji, Karim, & Rahman, 2005).

Researchers in China have also suggested an association between arsenic exposure and mental health problems (Fujino, Guo, Liu, You, Miyatake, & Yoshimura, 2004). Moreover, arsenicosis has been associated with reduced intellectual function in children, and overall neurologic effects in adults (Wasserman, Liu, Parvez, Ahsan, Factor-Litvak, van Geen et al., 2004)

Additional studies have shown that co-exposure to arsenic and anilofos (a crop protection agent commonly used in Bangladesh) yields additive toxic effects in rat embryofetal development (Aggarwal, Wangikar, Sarkar, Rao, Kumar, Dwivedi et al., 2007). Similarly, arsenicosis in mice leads to liver apoptosis (Santra, Chowdhury, Ghatak, Biswas, & Dhali, 2007).


NOTE: If you would like full bibliographic information for any of the above citations, please let me know.

An Overview of Arsenicosis

In an effort to eliminate mortality associated with water-borne disease in the 1970s in Bangladesh, a nationwide effort organized by UNICEF saw the installation of millions of shallow tubewells, widely replacing untreated surface water as a source of drinking water. Tubewells are used by as many as 97% of the rural population. At this level of the water table, carcinogenic inorganic arsenic compounds are prevalent, thus exposing millions to a host of health complications.

Tubewells scattered throughout rural Bangladesh are supplying the populace with arsenic-contaminated water. Consequently, an estimated 35 million inhabitants of rural Bangladesh are at elevated risk of developing complications associated with chronic arsenic poisoning. Chronic arsenic poisoning is defined as the effects of long term arsenic exposure from the consumption of contaminated water. The presence of excessive levels of arsenic in the body is known as arsenicosis—a condition that currently affects as many as 2 million individuals with varying degrees of symptomology.

Arsenicosis symptomology is classified into four distinct stages. The pre-clinical stage occurs within the first few years of exposure, and elevated arsenic levels can be detected in the urine and tissue. The second, clinical stage is characterized by skin lesions, gangrene, keratosis, and melanosis—typically on the hands, feet, and trunk—and tends to manifest itself between five and ten years of exposure. The third stage involves pronounced external expressions in addition to complications with internal organs. The final stage, occurring after approximately 20 years of exposure, is marked by the development of cancers of the skin, bladder, kidneys, and lungs. There is currently no known cure for the symptoms of arsenic poisoning, thus intervention efforts have been strongly directed at modes of prevention.

In addition to the physical complications associated with arsenicosis, there are myriad social implications as well. The poor dissemination of reliable information not only precludes awareness of dangers and consequences associated with drinking contaminated water; it also prevents rural Bangladeshi societies from recognizing and understanding arsenic poisoning. The early, visible symptoms of arsenicosis are mistakenly associated with leprosy. Even in cases in which symptoms are recognized as those of arsenicosis, the disease mechanisms are not well understood, and sufferers are consequently stigmatized and marginalized. Women who suffer from arsenicosis are considered unmarriageable; children of arsenicosis patients are excluded from schools. Arsenicosis is still, in many areas, perceived as a contagious disease. In some districts, superstition leads many to view affected persons as having been cursed by God or evil spirits.

While some studies have targeted the social and cultural aspect of arsenicosis, there is a great deal still to explore in that vein. There are several particular areas in which further anthropological analysis could be applied to work toward alleviating this public health crisis--more on this in an upcoming entry.

Welcome!

Hello!

I've started this blog as--hopefully--an easy way for me to communicate with everyone while in Bangladesh. For anyone who may not be familiar with the details, I've just recently been awarded a Fulbright research grant to study arsenic poisoning in rural Bangladesh, and, admittedly, I'm absolutely thrilled to have been given this opportunity!

I'll be leaving at the end of December or beginning of January for a year of classes and research: I will be affiliated with the BRAC University School of Public Health and BRAC, an NGO based in Dhaka. See the links to the right for information about these and other organizations

So, once I arrive in Bangladesh, I'll offer postings about my experiences there. Until then, however, I thought I would use my time to outline the problem of arsenicosis, my intended research, and possibly to discuss the adventure that is Teaching Myself Bengali.

Thanks for reading, and feel free to offer comments!
-Alicia