i F O R E W O R D ________________________________________________________________________ Arsenic Contamination in groundwater has emerged as a serious public health concern in many areas of Pakistan. In the provinces of Punjab and Sindh, over 20 percent and 36 percent of the population is exposed to arsenic contamination respectively. It may be reasonable to disregard the arsenic contamination in groundwater up to 50 ppb, but beyond this threshold value its presence in drinking water is considered highly dangerous. Although various initiatives are being undertaken by the governmental organizations in the country to address arsenic contamination, a lot of work still needs to be done on war footing. A resource integration approach is envisioned by the Ministry of Science and Technology, putting all the available resources together under a unified command to have more beneficial qualitative and quantitative outcomes. This visionary concept has been transformed and translated into the National Action Plan for Arsenic Mitigation (NAPAM – 2007-2011). Under this plan, arsenic contamination will be addressed comprehensively, within policy guidelines of the Government, covering the entire range of activities to identify and mitigate the arsenic contamination. I acknowledge with gratitude commendable role of UNICEF (Pakistan) and Water Quality Directorate of the Pakistan Council of Research in Water Resources (PCRWR) under the guidance of its Chairman in the detection of arsenic in groundwater since 1994. The continuous technical and financial support of UNICEF to PCRWR, Punjab and Sindh Governments in organizing activities for arsenic screening, mitigation and arranging awareness seminars is highly appreciated. I would also like to take this opportunity to thank, UNICEF Islamabad Office (Pakistan) for their help in the formulation of the National Action Plan for Arsenic Mitigation and their active support in overall monitoring of water quality. Finally, I would like to invite all to join hands to support the National Action Plan for Arsenic Mitigation from groundwater of Pakistan. Ch. Nouraiz Shakoor Khan Federal Minister for Science and Technology
Transcript
i
F O R E W O R D ________________________________________________________________________
Arsenic Contamination in groundwater has emerged as a serious public health concern in many areas of Pakistan. In the provinces of Punjab and Sindh, over 20 percent and 36 percent of the population is exposed to arsenic contamination respectively. It may be reasonable to disregard the arsenic contamination in groundwater up to 50 ppb, but beyond this threshold value its presence in drinking water is considered highly dangerous.
Although various initiatives are being undertaken by the governmental organizations in the country to address arsenic contamination, a lot of work still needs to be done on war footing. A resource integration approach is envisioned by the Ministry of Science and Technology, putting all the available resources together under a unified command to have more beneficial qualitative and quantitative outcomes. This visionary concept has been transformed and translated into the National Action Plan for Arsenic Mitigation (NAPAM – 2007-2011). Under this plan, arsenic contamination will be addressed comprehensively, within policy guidelines of the Government, covering the entire range of activities to identify and mitigate the arsenic contamination.
I acknowledge with gratitude commendable role of UNICEF (Pakistan) and Water Quality Directorate of the Pakistan Council of Research in Water Resources (PCRWR) under the guidance of its Chairman in the detection of arsenic in groundwater since 1994. The continuous technical and financial support of UNICEF to PCRWR, Punjab and Sindh Governments in organizing activities for arsenic screening, mitigation and arranging awareness seminars is highly appreciated.
I would also like to take this opportunity to thank, UNICEF Islamabad Office (Pakistan) for their help in the formulation of the National Action Plan for Arsenic Mitigation and their active support in overall monitoring of water quality. Finally, I would like to invite all to join hands to support the National Action Plan for Arsenic Mitigation from groundwater of Pakistan.
Ch. Nouraiz Shakoor Khan Federal Minister for Science and Technology
ii
T A B L E O F C O N T E N T S
FOREWORD ................................................................................................................................................. i
EXECUTIVE SUMMARY .......................................................................................................................... v
1.4 ARSENIC CONTAMINATION IN OTHER COUNTRIES............................................................. 3
1.5 TECHNOLOGY FOR ARSENIC REMOVAL .................................................................... 3 1.6 ADVOCACY, SOCIAL MOBILIZATION AND AWARENESS RAISING.................................... 4
1.7 FUTURE DIRECTION OF ARSENIC MITIGATION ..................................................................... 5
CHAPTER 2. CURRENT STATUS OF ARSENIC CONTAMINATION AND MITIGATION......... 6
Annexure A: Work Completed by PCRWR on Three Options of Arsenic Removal Technologies ............. 29
Annexure B: Recommendations of Seminars/Workshops............................................................................ 34
Annexure C: Map of Arsenic-Affected Districts.......................................................................................... 44
Annexure D: Other Relevant Details of PCRWR Project ............................................................................ 45
Annexure E: Screening of Water Sources - Protocols ................................................................................. 49
Annexure F: The Geological Survery - Survey Protocol.............................................................................. 51
Annexure G: Alternative Water Supply - Protocol....................................................................................... 53 Annexure H: Sample Protocols .................................................................................................................... 59
Annexure I: Types of Adsorbents and their Arsenic Removal Efficiencies ................................................. 64 Annexure J: Summary of Technologies for Arsenic Removal ..................................................................... 65
iv
List of Tables and Figures
Table 2.1: Results of National Survey for Arsenic Contamination ............................................................ 7
Table 3.1: Summary of Proposed Activities for Documenting Health Effects ........................................ 13
Table 3.2: Proposed Actions for Provision of Alternate Sources of Water.............................................. 14
Table 3.3: Summary of Cost by Annual Phasing ..................................................................................... 23
Figure 3.1: Overview of Structure and Activities of National Action Plan for Arsenic Mitigation .......... 19
Arsenic contamination of water has emerged as a serious public health concern in Pakistan. The proposed National Action Plan is the outcome of consistent consultation with all the agencies and organisations concerned with the provision of safe drinking water in Pakistan. Technical groups met in several seminars and workshops to develop recommendations for future course of action to combat this emerging menace. Workshops held observed that the efforts and resources of various Governmental and Non-Governmental Organizations working in this field needed integration. Accordingly, they recommended the preparation of a National Action Plan for Arsenic Mitigation in Pakistan. In light of the recommendations of provincial seminars, a national action plan for arsenic mitigation is prepared. The roles and responsibilities of various govt. agencies and community are clearly defined in the plan.
The strategies and objectives of the national action plan for arsenic mitigation include the following:
• Establishment of integrated institutional arrangement for enhanced project implementation capacity;
• Development of coordination mechanism amongst all the implementing agencies at various levels of administration with government(s), NGOs and donor agencies;
• Policy decisions and legislation to enforce and develop a national policy and strategies on arsenic prevention and mitigation in Pakistan as guidelines for the implementation of national action plan;
• Monitoring and surveillance of water quality/ aquifer mapping / treatment and data base thereof;
• Establishment of case diagnosis / management of affected arsenicosis by health department;
• Developing social mobilization approaches including communication strategies for advocacy of decision makers at all levels and effective education/mobilization to create awareness and involvement of communities for effective programme implementation through behavioral change on use of safe water, improved sanitation and hygiene; and
• Developing cost-effective water treatment technologies and establishment of applied research studies institutions and infrastructures.
Major activities which will be carried out under this action plan include the following:
• Hyderogeological investigation and water quality monitoring;
• Identification of alternative water supply for provision of safe drinking water in high risk areas, treatment of ground and surface water, rain water
vi
harvesting and sustainable mechanism for monitoring and surveillance at different levels, capacity building and social mobilization;
• Diagnostic and case management for creating awareness, behavioral change through social mobilization and education, communication, capacity building at various levels, arsenicosis case diagnosis protocols, and arsenicosis case management;
• Development of arsenic removal technologies for of house hold and community based arsenic removal filters;
• Finalization of monitoring and evaluation of protocols for arsenic screening and mitigation; and
• Involvement and participation of community union councils in arsenic mitigation and enhancing their capacity for effective participation.
The national action plan for arsenic mitigation has been planned for a period of five years (2007–2011). Particularly, the arsenic mitigation measures, which include alternative water supply and treatment of arsenic contaminated water, would span over the entire period of the action plan as a continuous activity.
1
Chapter 1. INTRODUCTION
1.1 BACKGROUND
Arsenic contamination in groundwater of Pakistan has emerged as a serious public health concern during the last decade. Preliminary investigations completed in 30 districts of the country show arsenic contamination in Southern Punjab and Central Sindh. The PCRWR is currently implementing a project to investigate the presence of arsenic contamination in the remaining districts of Punjab and Sindh provinces. Some work on mitigation of arsenic contamination has also been undertaken which has mainly focused on the development of low cost arsenic testing kits and mitigation technologies. To provide arsenic free drinking water, about 100 low cost arsenic removal plants have been installed in primary girl schools of both Southern Punjab and Central Sindh.
1.2 DESCRIPTION OF ARSENIC
Arsenic is an element that occurs naturally in rocks, soil, water, air, plants, and animals. Arsenic is a metalloid, which exhibits both metallic and nonmetallic chemical and physical properties. The primary valence states for arsenic are 0, -3, +3 and +5. Although arsenic is found in nature in small quantity in its elemental form (0 valence). It occurs most often as inorganic and organic compounds, either as the As (III) (+3) or As (V) (+5) valence states. The trivalent forms of inorganic arsenic [As (III) (e.g. arsenite, H3AsO3)] and the pentavalent forms [As (V) (e.g. arsenate, H2AsO4
-, HAsO4-2)] are inorganic
species that tend to be more prevalent in water than the organic arsenic species (Irgolic, 1994; Clifford and Zhang, 1994). The dominant inorganic species present in water is largely a function of the pH and the oxidizing/reducing conditions that affect the need for pretreatment and removal. Arsenates are more likely to occur in aerobic surface water and arsenites in anaerobic groundwater.
1.3 SOURCES OF ARSENIC CONTAMINATION
1.3.1 Natural Sources of Arsenic
There are numerous natural sources as well as human activities that may introduce arsenic into food and drinking water. The primary natural sources include geologic formations (e.g. rocks, soil, and sedimentary deposits), geothermal, and volcanic activity. Arsenic and its compounds comprise 1.5 to 2 percent of the earth’s crust. While concentrations of arsenic in the earth’s crust vary, the average concentrations are generally reported to range from 1.5 to 5 mg/kg. Arsenic is a major constituent of many mineral species in igneous and sedimentary rocks. It is commonly present in the sulfide ores of metals including copper, lead, silver, and gold. There are over 100 arsenic-containing minerals, including arsenic pyrites (e.g., FeAsS), realgar (AsS), lollingite (FeAs2, Fe2As3, Fe2As5), and orpiment (As4S6). Geothermal water can be a source of inorganic arsenic in surface water and ground water. Welch et al. (1988) identified fourteen areas in the western United States where dissolved arsenic concentrations ranged from 80 to 15,000 µg/L. In addition, natural emissions of arsenic are associated with forest fires and grass fires. Volcanic activity
2
appears to be the largest natural source of arsenic emissions to the atmosphere (ATSDR, 1998).
1.3.2 Industrial Sources of Arsenic
Major present and past sources of arsenic include wood preservatives, agricultural uses, industrial uses, mining and smelting. The human impact on arsenic levels in water depends on the level of human activity, the distance from the pollution sources, and the dispersion and fate of the arsenic that is released. The production of chromate copper arsenate (CCA), an inorganic arsenic compound and wood preservative, accounts for approximately 90 percent of the arsenic used annually by industry in the United States (USGS, 1998; USGS, 1999).
Organic forms of arsenic are constituents of some agricultural pesticides currently used in the U.S. Monosodium methanearsonate (MSMA) is the most widely applied pesticide. It is used to control broadleaf weeds and is applied to cotton (Jordan et al., 1997). Small amounts of disodium methanearsonate (DSMA, or cacodylic acid) are also applied to cotton fields as herbicides.
1.3.3 Dietary Sources
Because it occurs naturally, the entire population is exposed to low levels of arsenic through food, water, air, and contact with soil. The National Research Council report (NRC, 1999) assumed that for fish and seafood, inorganic arsenic is 10 percent of the total arsenic and that other food contains entirely inorganic arsenic. The NRC report characterizes inorganic arsenic intake from food in the U.S. as being 1.3 µg/day for infants under one-year old, 4.4 µg/day for two-year olds, almost 10 µg/day for 25–30 year-old males, with a maximum of 12.5 µg/day for 60–65 year-old males (females had lower arsenic intake in every age group). Similarly, the 2 L/day assumption of adult drinking water intake used to develop the Maximum Contaminant Level Goal (MCLG) rather than representing intake by the average person, represents that of a person in the 90th percentile.
1.3.4 Environmental Sources
Internal exposure after skin contact with water or soil containing arsenic or inhalation of arsenic from air is believed to be low.
Studies of inorganic arsenic absorption from skin from cadavers estimated 0.8 percent uptake from soil and 1.9 percent uptake from water over a 24-hour period (Wester, et al., 1993). The EPA’s arsenic health assessment document for the Clean Air Act (US EPA, 1984) cited respiratory arsenic as being about 0.12 µg/day from a daily ventilation rate of 20 m3 using a 1981 national average arsenic concentration of 0.006 µg/m3.
3
1.4 ARSENIC CONTAMINATION IN OTHER COUNTRIES
A number of large aquifers in various parts of the world have been identified with problems of arsenic contamination with concentrations above 50 ppb, the most noteworthy occurrence are in parts of Argentina, Bangladesh, China, Northern China, Hungry, India (West Bengal), Mexico, Romania, Taiwan and many parts of the USA.
1.5 TECHNOLOGY FOR ARSENIC REMOVAL
Review of arsenic removal technologies has revealed that many technologies have been developed in many parts of the world for the removal of arsenic from large municipal treatments plants or at community or household levels. All of the technologies for arsenic removal rely on oxidation-reduction reaction, precipitation, adsorption and ion exchange, solid liquid separation, physical exclusion and coagulation. These technologies remove arsenic but have certain drawbacks such as high cost, energy dependent, post treatment requirement etc. In recent years, a tremendous amount of research has been done to develop low cost technologies for arsenic removal.
A tube well, the only source of water for this village in Punjab, bears arsenic contamination up to 300– 400 ppb
Presence of excessive levels of arsenic in ground water of areas of Sindh province has attained greater attention as the affected areas of the Sindh province such as Districts of Khairpur Mirs and Dadu have an estimated population of 18.76 million people. Major part of the population is from rural areas where the people are not aware of the health hazards of arsenic contamination in the drinking water. As arsenic is tasteless, colorless
4
and odorless even at higher concentration, so in many cases damage is done before knowing the cause. The magnitude of complexities of the arsenic problem makes it extremely difficult problem to handle. Added to this is usually the socio-economic situation of the people leveling in these areas. Most of the Central Sindh depends on groundwater for drinking, cooking and other domestic purposes. The presence of excessive arsenic beyond the WHO guidelines & PSQCA standards in groundwater of such areas has necessitated the need for simple and low cost techniques for the removal of arsenic from drinking water. Considering the socio-economic background of rural and urban population of these areas, it was highly appropriate to develop a simple, effective and affordable household filtration system to remove arsenic. The PCRWR has developed a low cost technology for the removal of arsenic from drinking water. The PCRWR has recently completed the work on three options of arsenic removal technologies (Annexure-A). These technologies will be promoted in the affected districts in near future with the coordination of UNICEF.
The same source is polluted further as the Perennial Irrigation Canal, the only limited surface water source
for the area, is glutted with the effluent of the nearby sugar mill and human activities.
1.6 ADVOCACY, SOCIAL MOBILIZATION AND AWARENESS RAISING
Various government agencies and other stakeholders, including UN agencies and NGOs have started the process of alliance building to address the problem of arsenic contamination. The Government of Punjab and Sindh took the lead by holding the following two provincial-level seminars/workshops to share data on the arsenic problem in Pakistan for the first time and to outline an action plan for its mitigation:
• Provincial Seminar on Arsenic Contamination in Drinking Water in Punjab, on April 12 -13, 2004 in Lahore;
• ‘Safe drinking water supply in Sindh Province: Arsenic problem and mitigation Measures’, on June 1-2, 2004 in Karachi; and
5
• ‘Safe drinking water: Health aspects of arsenic contamination’ organized by Ministry of Health, WHO on March 22, 2005 in Islamabad.
These seminars provided the formal basis for social mobilization and awareness raising. The recommendations of these seminars are given in Annexure-B. Local and national media have started very recently to cover the arsenic issue in the country and highlight arsenic mitigation activities. At the community level, awareness is being raised as representatives of NGOs, SAFWCO and SHED in Sindh and HRDS in Punjab are busy marking water sources with green paint to indicate safe sources or red to indicate sources unfit for human consumption, sharing basic information with communities on arsenic, and showing posters.
1.7 FUTURE DIRECTION OF ARSENIC MITIGATION
With formal recognition of the problem, the national and international and non-governmental agencies are expected to launch monitoring and mitigation programmes. An arsenic monitoring and mitigation will entail developing an institutional framework for carrying out a programme of hydrogeological activities to locate areas with arsenic contamination, and identify the origins and sources of arsenic contamination, developing alternative water supply options, and improved diagnostics and health care protocols. The future work should include, screening of the remaining areas of the Punjab, Sindh, NWFP and Balochistan provinces finding of alternate safe drinking sources for arsenic affected areas, causes of arsenic contamination, documenting the health effects of arsenic contaminated water, developing household and community level, low cost, arsenic removal technologies, social mobilization of communities and identifying and mobilizing financial resources for arsenic mitigation from Pakistan.
6
Chapter 2. CURRENT STATUS OF ARSENIC CONTAMINATION AND MITIGATION
2.1 PRELIMINARY INVESTIGATIONS (1999–2000)
From Nov. 1999 to Jan. 2001, the Pakistan Council of Scientific and Industrial Research (PCSIR), and the Pakistan Council of Research in Water Resources (PCRWR) of the Ministry of Science and Technology carried out a preliminary investigation on the prevalence of arsenic in drinking water sources. Six districts in northern Punjab: Jhelum, Chakwal, Attock, Rawalpindi, Sargodha and Gujrat were selected based on the following criteria:
• Areas draining coal and/or iron mining areas;
• Areas where geothermal waters are known to occur naturally;
• Areas with reducing groundwater, where compounds like dissolved iron, hydrogen sulphide, or methane are found; and
• Areas draining crystalline igneous rocks such as granites or basalts.
During the investigation, 308 samples were collected from these six potentially high-risk districts, taking one sample each from a grid size of 100 km2. These samples were processed at laboratory using a Hydride Generation Atomic Spectrometer. Analysis of the samples revealed that 14 percent had arsenic concentrations of over 10 ppb (WHO guideline value) and three percent (i.e. six samples/sites) above 50 ppb (Pakistan guideline value is 10ppb).
2.2 NATIONAL SURVEY (2001)
Based on the findings of the preliminary investigations described above, the Public Health Engineering Department (PHED) and Local Government and Rural Development (LG&RD) launched a national survey in 2001 to further assess the level of arsenic contamination. This time, one-third of all districts in the country (i.e. 35 of 104 districts) were selected from each of the four provinces.
Of the 8,712 samples, nine percent had arsenic above the WHO guideline value of 10 ppb and 0.70 percent of samples had arsenic concentrations above 50 ppb. However, analysis of 848 validation samples (10 percent of total samples) by Atomic Absorption Spectrometer (AAS) revealed that almost 30 percent of samples had arsenic concentrations over 10 ppb and seven percent above 50 ppb. It should be noted that laboratory results obtained by AAS are thought to be more accurate than those obtained using Merck field testing kits. The results by province are presented in Table 2.1.
7
Table 2.1: Results of National Survey for Arsenic Contamination Total Samples (No.) >10 ppb (%age) >50 ppb (%age)
District Field Lab Field Lab Field Lab Balochistan 619 71 1.30 1.40 0.0 0 NWFP 1560 156 0.30 22.0 0.0 0.6 Punjab 4315 428 12.2 36.0 0.60 9.0 Sindh 2218 193 11.0 26.0 1.40 10
Total 8712 848 9.0 28.0 0.70 7.0
As can be seen from Table 2.1, arsenic contamination is prevalent mainly in Punjab and Sindh provinces, where over 11 percent of field samples revealed an arsenic level above 10 ppb and 0.6 to 1.4 percent samples over 50 ppb. NWFP and Balochistan had comparatively little arsenic contamination, except one district in NWFP (Mardan) for which laboratory results indicated the presence of arsenic over 50 ppb. Arsenic affected areas in Pakistan are shown in Annexure-C.
2.3 ARSENIC MITIGATION (2002–2004)
Following the national survey for arsenic (see above), a team from PCRWR, Sindh and Punjab Local Government Departments, and UNICEF visited Bangladesh to observe the country’s experience with arsenic mitigation. This experience was then applied in Punjab by local governments and in Sindh by NGOs in coordination with local governments. The major activities undertaken under the arsenic mitigation programme included:
• Capacity development of government officials and NGOs;
• Blanket testing/screening of water sources in the four districts (Dadu, Khairpur, Nawabshah, and Tharparkar) in Sindh province that ranked highest in arsenic contamination during the national survey;
• A first round of village-level surveys for arsenic contamination in the three districts (Multan, Rahimyar Khan, and Bahawalpur) that had ranked highest for arsenic contamination in Punjab, followed by five more districts (DG Khan, Layyah, Muzaffargarh, Sargodha, and Jhang) in Punjab in the second round of focused surveys;
• Blanket testing in Multan, Rahimyar Khan, and Bahawalpur in Punjab based on results of focused survey;
• Research at PCRWR on development of low-cost household filters for treating arsenic contaminated water;
• Research at PCRWR on development of local field testing kits;
• Research at PCRWR on development of Arsenic Removal Technology (ART) for small communities and households;
• Social mobilization and advocacy;
8
• Awareness raising based on the results of blanket testing; and
• Epidemiological study in Punjab on prevalence of arsenicosis.
Most of the above activities have been completed whereas following activities are still in progress:
1. Arsenic Monitoring and Mitigation in Pakistan (2005-2008);
2. Development of SOPs for Sampling and Analysis of Arsenic in Drinking Water;
3. Capacity Development programme for Arsenic screening and mitigation;
4. R & D on low cost house hold and community WTU/ARTs and Testing Kits;
5. Training of Master Trainers (TOT) on various dimensions of water treatment units; and
6. Research papers and articles on arsenic profile and ARTs in the effected regions of Pakistan.
9
Chapter 3. NATIONAL ARSENIC MITIGATION PLAN
3.1 INTRODUCTION
Arsenic investigation in Pakistan was seriously considered during latter part of nineties. The UNICEF Pakistan took the leading role for arsenic screening. The scope of the study and participation of national organizations increased with the passage of time. The work on the subject progressed on both fronts of screening and developing technologies for arsenic mitigation. Lately PCRWR, MoST, Provincial Governments and International organizations are working on arsenic. In order to stream line the energies and pool up the resources a national action plan was needed.
3.2 OBJECTIVES
The overall objectives of National Action Plan for Arsenic Mitigation are:
• To determine the extent of arsenic contamination in groundwater; • To identify the major activities and integrated approaches for arsenic
mitigation; • To establish institutional arrangements and develop capacity in arsenic
mitigation; • To integrate national and non-governmental resources to combat arsenic
contamination; • To formulate coordination mechanisms and technical groups on various
aspects of arsenic mitigation in order to improve qualitative and quantitative assessment of arsenic toxicity on the human health;
• To promote legislation, policy development and strategy formulation on arsenic mitigation such as making arsenic testing compulsory and establishing guideline values;
• To formulate management and mitigation protocols; • To evolve mechanisms for capacity building of health departments on case
diagnosis and treatment of patients; • To establish sustainable water quality monitoring and surveillance systems
at the community level; • To establish effective and sustainable behavioral change programmes on
arsenic mitigation including development of communication support materials; and
• To integrate research work of various institutions, organizations and NGOs on key areas such as on geological, hydrological, hydrogeological research and development of local and affordable treatment technologies.
10
3.3 MAJOR COMPONENTS OF MITIGATION PLAN
The major components of National Arsenic Mitigation Plan includes arsenic contamination screening, identification of alternate safe water sources and development of technologies, institutional framework and finally the identification of financial resources for the implementation of plan. Essential details of each of the component are given below:
3.3.1 Screening of Arsenic Contamination
Screening of ground waters of Pakistan is essential component of arsenic mitigation plan. The screening studies conducted so far covers 30 districts of 124 districts of Pakistan. The investigation conducted earlier were not properly planned to cover the spatial extent of the country on a pre-determined grid size. Therefore there is a need to conduct screening of all Indus basin by year 2009. Apart from the screening carried out by UNICEF with assistance from local agencies in 30 districts, the Pakistan Council of Research in Water Resources (PCRWR) has prepared a project worth 39 Million Rupees for arsenic screening in the remaining districts of the Punjab and Sindh provinces.
Under this project UNICEF and PCRWR has already undertaken detailed screening of Rahimyar Khan, Bahawalpur and Multan districts. Other relevant details of PCRWR project are given in Annexure-D. Details of screening of water resources are given in Annexures E, F and G.
3.3.2 Effect of Arsenic Contaminated Water on Health
The long-term health effects of arsenicosis are not yet fully known. The probable complications include: non-pitting oedema, peripheral vascular disease (gangrene), chronic ulcers, Bowen’s Disease (pre-malignant skin condition), Squamous Cell Carcinoma (SCC), Basal Cell Carcinoma (BCC), hepatopathy, nephropathy, cancer of internal organs (urinary bladder, lung and prostate), adverse pregnancy outcomes (spontaneous abortion, still birth and miscarriages), diabetes mellitus, and hypertension.
A diagnosis of arsenicosis is based upon symptoms of skin lesion manifestation: hyperkeratosis on the palm and soles (causes are still to be elucidated), hyper – pigmentation and or hypo–pigmentation that emerges on the skin of the unexposed body areas (causes yet not established). Common non-dermatological symptoms are weakness and asthenia, conjunctival illness, respiratory illness, i.e. chronic cough, bronchitis and asthma, peripheral neuropathy, i.e. tingling, numbness, burning and pain. Peripheral neuritis, i.e. sensory and motor polyneuritis and myophagism is another possible symptom for which the causes are not yet understood.
These symptoms are associated with arsenic levels in urine or hair samples, which are significantly higher than the normal levels in non-epidemic areas of the same region.
The Institute of Public Health (IPH), Government of Punjab, carried out an initial epidemiological study in 2003 on the prevalence of arsenicosis due to ingestion of arsenic through drinking water in seven districts of Punjab: Bahawalpur, Layyah, DG Khan,
11
Multan, Muzaffargarh, Rahimyar Khan, and Jhang. During the study of 38,794 people, 28,545 individuals were screened for arsenicosis, including analysis of fingernail samples for arsenic levels. For the screened population, 40 cases of arsenicosis (three clinical and 37 borderlines) were detected, making the prevalence of clinical arsenicosis and borderline arsenicosis 11 and 130 per 100,000 persons respectively (IPH, 2003).
The mean arsenic concentration in nails among persons consuming water from the stated sources for 10 or more years was found to be almost 70 percent (0.08 mg/kg) higher than in those consuming for water less than 10 years. Mean arsenic in nails among persons consuming water with arsenic more than 50 ppb was 0.1964 mg/kg, about 250 percent higher than in those consuming water with arsenic less than 50 ppb.
The study acknowledged arsenic contamination in drinking water to be an emerging public health problem in Pakistan. It concluded that although prevalence of dermatological lesions related to arsenicosis was low, a large proportion of the population was at risk of developing arsenicosis if it remained exposed for a longer duration to the existing high levels of arsenic in water. It should also be noted that IPH conducted a similar study in northern Punjab (Jhelum, Gujrat, and Sargodha) as a follow up to the preliminary investigation on arsenic contamination described earlier. The combined figure for clinical and borderline dermatological arsenisosis for all 10 districts was 92/100,000 and 242/100,000 respectively. Similar studies are urgently needed in Sindh, where arsenic contamination is much worse than in Punjab and where unconfirmed cases reported by non-governmental sources are increasing.
Under the National Action Plan for Arsenic Mitigation the following health related aspects will be covered:
• Developing legislation and policy on arsenic mitigation such as making arsenic testing compulsory, establishing a guideline value for arsenic in water supplies, short-term and long-term mitigation policy, compulsory screening for arsenicosis in government hospitals especially in arsenic affected areas;
• Establishing case diagnosis and management protocol systems in the Health Department for suspected arsenicosis, including registration of confirmed cases.
• Building capacity of health departments to diagnose and treat patients; • Establishing effective and sustainable behavioral change programmes on
arsenic mitigation including development of communication support materials;
• Develop training guides/educational materials; • Establishing and maintaining an efficient, effective and referral chain for
clinical arsenicosis case diagnosis; • Detection and reporting of cases should be implemented in consideration of
chain of evacuation of casualty; • Technical support to existing laboratories for epidemiological and diagnosis
investigation;
12
• Establishment of a multi-disciplinary, autonomous, International Centre for arsenic mitigation in Pakistan to act as centre of excellence for arsenic related research, quality control of technologies, and to oversee coordination of activities;
• Issues related to arsenicosis, both clinical and public health should be incorporated into the curriculum of the medical institutions; and
• Establishment of a multi-disciplinary National Task Force for the identification of arsenicosis and its causes, formulation of strategies to diagnose, treat, and prevent, and subsequent monitoring in order to effectively combat the menace of arsenic contamination.
The activities proposed in the action plan are given in Table 3.1. Sample protocols for diagnostic of arsenicosis are given in Annexure-H.
3.3.3 Alternate Supply of Safe Drinking Water
Provision of safe drinking water to residents of arsenic effected areas must be made on emergency basis. Based on the water quality analysis, the sources of water being used should be clearly marked to indicate arsenic free water source and arsenic contaminated water source, preferably with green and red colors. The residents should be briefed about the health hazards of arsenic contaminated water and advised to use arsenic free water. In areas where apparently no sources of arsenic free water are available hydrological investigations and use of appropriate technology options will be considered. Proposed actions for provision of alternate sources of water are summarized in Table 3.2. Under provision of safe drinking water to users in arsenic contaminated water supply areas, the following short term and long term actions will be undertaken.
3.3.3.1 Short term Actions
• Physical and chemical treatment of contaminated surface or ground water through construction of rapid sand filtration plants, chlorination, household treatment (HHT) and/or arsenic removal technology (ART);
• Digging deep wells since they have been found to be safer; • Dug wells where construction is technically feasible and safer water is
available; • Rainwater harvesting;
3.3.3.2 Long Term Actions
Long-term options in areas with arsenic contamination problems include provision of piped water supply from arsenic free sources, development of new treatment technologies for communities, prevention through early detection of arsenic contamination of water sources and encouragement of changes in behaviors among affected communities to use the arsenic free water for drinking and cooking.
13
Table 3.1: Summary of Proposed Activities for Documenting Health Effects Specific
Activities Location WHERE
Actions WHAT
Implementation HOW
Responsibility WHO
Time frame WHEN
Social mobilization for behavioural change communication
Affected areas
KAP *Survey * Mass media *Education *Strategizing
*Cross-sectional survey *Mixed-media approach
* Provincial govt support * EDO health *IPH *TMAs
Immediate
Capacity development
At various institutions in affected areas
*Impart training in phases *Comprehensive training plan for different population segments
Training in the form of *lectures *plays *demonstrations *workshops *seminars
*Develop protocol *Disseminate to healthcare providers
*Health protocol be drafted in the light of arsenic-affected patients
*IPH *HAS *Provincial Health Ministries
* Draft protocol attached *Immediate
Arsenicosis case management protocol and patient registration
*Identify arseniccosis patients *Case management component in HMIS monthly report
*Through existing HMIS *National HMIS Cell *Provincial Health Depts
Immediate action
Information management (collection, collation and dissemination )
*Data collection and statistical analysis *Dissemination to all concerned
* Field staff, Lady Health Visitors and BHU to collect data
* DHOs * TMAs * EDOs health
Immediate action
Health research
* Research for new medicines *Precautionary measures/method
* Test and trials in light of real case studies
IPH HAS Individual research scholars
Immediate action
Resource mobilization *To energize/ identify
resources * Work shops * Seminars
*DGLGs *TMAs
Immediate action
Policy development and legal framework
*Identify stakeholders *Formation of groups of experts Promote legislative recognition of 50 ppb permissible limit
*Effects of 50 ppb limit medically to be checked *Through constant studies, observation and personal experience * PCRWR to coordinate among the various organizations
Ministry/Dept of Health *Provincial Health Ministries /Govts *IPH *HSA * Individual researchers and scholars *Medical universities and institutions WHO
After approval of the NAPAM
14
Table 3.2: Proposed Actions for Provision of Alternate Sources of Water
Activities
Specific Areas Location
Actions WHAT
Implementation HOW
Responsibility WHO
Time frame WHEN
1 Provision of safe drinking water – on emergent basis
Worst arsenic hit areas
*Switching over to safe drinking *Arranging water treatment
Use of pond, canal and rainwater after treatment
*TMAs *Irrigation Dept. * PHED *UCs
* Immediate whenever AC found in drinking water * Emergent Option
2 Treatment of : surface water groundwater
Arsenic hit areas
*Physical and chemical treatment
*Construction of rapid sand filtration plants *Chlorination *HHT
PHED Irrigation Dept TMAs
Immediate
3
Short-term option Deep wells – (safe) Dug wells Rainwater harvesting Treatment of surface water Treatment of AC water
Arsenic stricken areas
*Rehabilitation of existing sources *Construction of dug/ring wells *Water treatment facilities
*Checking for suitable water in deep wells *Dug wells where construction is technically feasible *Developing AC technologies
*PHED *TMAs *Irrigation Deptt *UCs
Immediate where water scarcity of surface water is envisaged
4 Treatment of deep and shallow well water
Arsenic hit areas
After testing groundwater for salts, nitrates, sulphates, hardness etc
By water monitoring teams and local PCRWR labs
UCs TMAs PCRWR
Immediate when plans at. 1 & 2 do not materialize
5 Provision of mobile/ transported water supply
where surface and deep wells fail
Potable water (drinking water) will be transported by water tankers from safe sources
Water tankers from govt pool and hired from private firms will be used to transport safe water
PHED TMAs UCs
Immediate as a last resort when all options from. 1 to 4 fail
6 Long-term option *Provision of piped water supply
arsenic affected areas
Nearest safe water sources will be tapped for piped water supply for affected areas
Funds for the project will be arranged by PHED and TMAs with ‘’pay as you go” ops & maint
PHED TMAs UCs
After steps 1 to 5 when no surface/deep wells available
7
Monitoring and surveillance (sustainable mechanism)
Lab facilities at tehsil and field kits at UCs level
With the assistance from R & D orgs , universities and PhD scholars
Continuous monitoring and surveillance mechanisms to be developed
*R&D org *DG LG *PCSIR *PCRWR
At start of the Action Plan Actual sampling/ monitoring six months after the provision of facilities
8 *Institutional arrangements and capacity building: Policy formulation
In the lT of NWQDS PCRWR
*Immediate action *Proposed protocol attached
Continued..
15
Table 3.2 (Contd) * Institutional support
*m/o S&T *PCRWR *PHED
*Proposed protocol attached
Capacity building DGLGs
*Participation *Proposed protocol
attached
*Coordination
Technology promotion.
* By active involvement *Delegation of certain powers *By incentive *By frequent communication. & site visits *Holding of meetings *Developing & sharing of new technology
*Role of LGs *PCRWR *NGOs *Welfare organization *Community * NCHD * Local Govt *Local Govt * NGOs
10 Resource mobilization Mobilizing human and material resources
*Local Govt *NGOs *TMAs *UCs
Immediate
11. Community involvement and ownership
Engaging the community through active involvement in decision making
*Local Govt *NGOs *NCHD *Individual volunteers
Immediate
12. Behavioural changes *Develop social mobilization including comprehensive communication strategies
*Provincial and local govts. NGOs Immediate
16
3.3.4 Appropriate Arsenic Removal Technologies
Pakistan Council of Research in Water Resources (PCRWR) has developed low- cost filters for treating arsenic-contaminated water at the household level. Considering the socio-economic background of rural and urban populations in the arsenic affected areas, three low cost arsenic removal technologies – clay-pitcher, plastic gravity flow, and ceramic cartridge arsenic removal filters – were investigated. (PCRWR, 2003b) After six months of monitoring, the clay pitcher arsenic removal filter emerged as the most feasible technology in terms of arsenic removal efficiency, life of media used, estimated cost, as well as simplicity and ease of use. It reduced arsenic from a pre-treatment value of 300 ppb to 0.2 ppb. Types of Absorbents and their Arsenic Removal Efficiencies are given in Annexure-I and Summary of Arsenic Removal Technologies are given in Annexure-J.
3.3.5 Institutional Framework
3.3.5.1 History of Environmental Regulations
The history of environmental regulation in Pakistan begins with the promulgation of National Environmental Quality Standards (NEQS) under the Pakistan Environmental Protection Ordinance, 1983. Approval of the National Conservation Strategy by the cabinet in the early 1990s started the debate and enforcement of NEQS in Pakistan. The Pakistan Environmental Protection Council met for the first time in nine years after the promulgation of the Ordinance. The process of approval of NCS had the full support of the Ministry of Environment and NGOs in the country.
In April 1996, the Pakistan Environmental Protection Council (PEPC) set up the Environmental Standards Committee known as the Shamslakha Committee, after its Chairman. The task of the Committee was to review and rationalize the NEQS. At the same time, the Ministry of Environment and Pakistan EPA prepared a draft Environmental Protection Act which was widely circulated to all relevant stakeholders. Ministry of Environment, Pakistan EPA, NGOs, and industry institutions organized many workshops, seminars, and meetings to solicit comment on the Act. In these events, the main theme remained consensus building among stakeholders for the finalization of the Act. The comments and concerns raised by the stakeholders during consultations were incorporated in the Act and finally the Parliament of Pakistan on the basis of unanimous decision passed the Act and the President of Pakistan promulgated the Environmental Protection Act, 1997 on February 11, 1997.
Under a notification issued by the Ministry of Environment on 27 November 2004, the National Coordination Committee on Water and Sanitation (NCCWS) was constituted under the chairmanship of Federal Secretary of Environment, Ministry of Environment. Sixteen other members were taken from various organizations and agencies with the following Terms of Reference:
• Review existing policies, legislations, standards and guidelines related to drinking water and sanitation and propose changes where required and also develop new policy guidelines if deemed necessary;
17
• Review implementation and enforcement of legislation/policies/standards/ guidelines related to drinking water and sanitation;
• Establish a national forum for safe drinking water and sanitation in the context of environment. The Committee may constitute a National Technical Committee (NTC) to facilitate its functions;
• The Committee shall propose federal and provincial Governments, NGOs or any other institute to develop and execute projects/plans in drinking water and sanitation;
• Review annual report on state of drinking water and sanitation in the country and issue direction accordingly;
• The Committee shall meet quarterly in a year; and
• Committee may co-opt any expert/organization as its member as and when deemed necessary.
The formation of the Coordination Committee at federal and provincial levels for drinking water and sanitation was an important step forward in addressing water quality problems, including arsenic contamination. Mitigating arsenic contamination, however, will require building on and this framework to develop institutions and infrastructure specifically targeted to this problem. The overall components of the Arsenic Action Plan are shown in Figure 3.1.
3.3.5.2 National Committee on Arsenic Mitigation
A National Committee on Arsenic Mitigation is proposed to regulate the works of various organizations at the national level. The objectives of the Committee will include:
• Establishing institutional arrangements conducive to ownership and developing capacity in arsenic mitigation; and
• Establishing coordination mechanisms and technical groups on various aspects of arsenic mitigation.
The proposed composition of the committee is given below:
a. Secretary, Ministry Science and Technology = Chairman b. Chairman PCRWR = Vice Chairman c. DG Ministry of Health = Member d. DG Ministry of Environment = Member e. DG Ministry of Education = Member f. DG LG&RD, Punjab = Member g. Director PM&EC, Sindh = Member h. DG LG&RD, NWFP. = Member i. DG LG&RD, Balochistan = Member j. DG LG&RD, AJ&K and NAs = Member k. DG Health Department of all the Provinces = Member
18
l. DG Public Health Engineering Department = Member m. Representative of WHO = Member n. Representative of Research Institutes = Member o. Representative of Universities = Member p. Representative of-UNICEF = Member/Secretary
The details of the constitution of the committee are shown in Figure 3.2.
3.3.5.3 Administrative Management at Federal Level
The National Steering Committee on Arsenic will be the supreme administrative and technical body with the following roles and functions:
• Integration of the national resources (government and non-governmental) for the purpose of arsenic mitigation;
• Assignment of specific tasks and division of responsibilities to various ministries, departments and agencies with the view to avoid overlapping of efforts and resources available;
• Formulation of policies, guideline values and water quality standards. The steering committee will also formulate legislative proposals (for approval of Parliament);
• Allocation of human and material resources to various agencies involved in arsenic mitigation measures;
• Competent authority to grant administrative approval up to Rs 5 M; • Establishment of priorities, scope, and timelines of mitigation efforts; • Approval of the arsenic mitigation technologies and methods; • Generating financial support through national and international donors; • Monitor ongoing projects at federal level; • Mandate to make and approve amendments in ongoing projects. • Chalk out/modify objectives of Action Plan; • Review Action Plan implementation; • Apprise donor agencies of progress of projects; and • Monitor ongoing projects at federal level.
19
Figure 3.1: Overview of Structure and Activities of National Action Plan for Arsenic Mitigation
SCOPING • Magnitude of problem • Identification of high-
risk areas and hot spots
SCREENING • Random testing/survey • Blanket testing ( 100%
water source test) • Other structured testing • Monitoring
preparation COMMUNITY PARTICIPATION CAPACITY DEVELOPMENT INSITUTIONAL AND LEGAL FRAMEWORK
PROVISION OF SAFE DRINKING WATER • Short term • Long term
TREATMENT OF SURFACE AND GROUNDWATER TREATMENT OF ARSENIC CONTAMINATED WATER
• Household Technology (HHT)
• Arsenic Removal Technology (ART)
RESOURCE MOBILIZATION CAPACITY DEVELOPMENT INSTITUTIONAL SUPPORT COMMUNITY PARTICIPATION COMMUNICATION RESEARCH DEVELOPMENT
DIAGNOSIS PROTOCOLS • Symptoms - physical
and subjective • Clinical test – urine • Develop case
identification, guidelines. • Health staff training in
case identification & management
• Capacity building: develop training materials
TREATMENT OF PATIENTS • Use Arsenic free water –
drink / cook • High protein, vitamin and
healthy diet • Abdominal symptoms
specifically treated • Development of case- management process DEVELOP ARSENICOSIS PROTOCOL BEHAVIORAL CHANGE COMMUNICATION Food chain analysis Treatment of affected Capacity development Epidemiological Research
EMERGENT ARSENIC REMOVAL TECHNOLOGIES TEST/MONITORING / EVALUATION OF VARIOUS TECHNOLOGIES SELECTION OF BEST AVAILABLE TECHNOLOGY PRODUCTION/MARKETING TRAINING /CAPACITY DEVELOPMENT RESEARCH DEVELOPMENT • Development of low cost
& sustainable household treatment technologies
• Development of indigenous & sustainable community-based treatment systems
LEGAL AND INSTITUTIONAL FRAMEWORK
National Committee on Arsenic Mitigation Headed by Chairman – PCRWR
Coordinate Arsenic Mitigation and Research Measures / Activities
Hydrogeological aspects
Alternative water supply options
Diagnostics and health care
Arsenic mitigation measures
Major interventions
20
Figure 3.2: Arsenic Mitigation Steering Committee
CHAIRMAN (SECRETARY, MINISTRY OF SCIENCE AND TECHNOLOGY)
3.3.6 Social Mobilization
Lack of awareness, illiteracy and unfavorable socio-economic conditions make the end users in villages/rural areas the most vulnerable to the adverse effects of water contamination. The active participation of the intended beneficiaries communities of arsenic mitigation is vital for the success of the programme. Lack of awareness and generally unfavorable economic conditions are also obstacles to mobilizing communities to get the best out of community-based programmes and projects. Therefore, the National Action Plan must include strategies for mobilizing communities and enhancing their capacity to participate effectively.
The concept of devolution instituted by the Government of Pakistan in 2002 provides a new opportunity to mobilize communities.
Director General Ministry of Health Director General
Ministry of Environment
Director General Ministry of Local
Government
UN Representative
Director PCRWR
Director PHED
Director General Local Government
Punjab
Director General Local Government
Sindh
Representative of NWFP/ Balochistan, FANA/AJK (PHED/LG)
VICE CHAIRMAN, Chairman PCRWR
21
UCs are the basic administrative units at grassroots level in Pakistan and should be given the leading role and responsibilities in organizing the local community to undertake resource, mobilization, monitoring and mass awareness. Initially, the inventory and water quality testing of tube wells can be undertaken by the UCs. The UCs can also assist in mobilizing basic health units for medical diagnosis of affected people. The local communities should also be empowered to undertake planning, implementation and management of safe water options. The communities should be imparted training to assist the implementation and monitoring of the arsenic project.
The private sector also has an important role in the arsenic mitigation efforts. Development of innovative, enterprising solutions by the private sector should be encouraged.
3.3.7 Cost Estimate for Implementation of Action Plan
This section briefly deals with preliminary cost estimates for the components envisaged in the present National Action Plan for Arsenic Mitigation. These cost estimates are based on the conceived targets by activities under each of the Plan’s components and probable expenditure governed by prevailing prices to complete the activities and achieve targets thereof.
3.3.7.1 Hydrogeological Investigation and Water Quality Monitoring
The hydrogeological investigations mainly focusing on would include; (i) random testing (4534 UCs), (ii) blanket testing (1075 UCs in high risk districts) and (iii) testing in identified arsenic contaminated districts and others critical areas reported from time to time. The cost estimate for these activities has been made at current prices as much possible. Mainly, the cost would cover the activities including; (i) water sampling and monitoring in the above said UCs and (ii) relevant database preparation and requisite mapping. Keeping in view the extent and magnitude of these activities, their total cost has been estimated as rupees 40.0 million.
3.3.7.2 Mitigatory Measures
Arsenic mitigation framework mainly, includes; (i) alternative water supply using appropriate technological innovations corresponding to the needs of the households in 1075 UCs, (ii) treatment of arsenic contaminated water at community level in the same 1075 UCs. These activities would be undertaken as a continuous process for the entire Plan period. The total cost to implement both the activities has been provisionally, figured out as rupees 200 and 250 million respectively. 3.3.7.3 Diagnosis of Arsenicosis Cases
Diagnosis of arsenicosis cases as an overall component mainly consisting of patient’s clinical tests and treatments, involves a total estimated cost of rupees 10.0 millions spanning over the Plan period of five years.
22
3.3.7.4 Development of Arsenic Removal Technologies
Development of arsenic removal technologies mainly, covering household level water treatment and development of potable water technologies at community level supported by economic viability to achieve the cost effectiveness both in terms of execution and operation/maintenance. The estimated cost of these activities has been estimated as rupees 20 million. 3.3.7.5 Impact Evaluation and Research
Impact evaluation and research as an essential part of the Plan would require about two percent of the total cost of investigation and physical components. This cost works out to be rupees 10 millions. This cost is the minimum keeping in view the objectives and planned impact evaluation and research activities. The cost estimates of Plan’s components are based on current prices which allow for future variation and inflations. Therefore the cost estimate prepared for the plan as these are preliminary estimates. A summary of the Plan costs by annual phasing is given in Table 3.3. 3.3.8 Resource Planning
3.3.8.1 Provision of Human Resources
Human resources will be provided by the following organizations and agencies:
• Technical support and manpower will be provided by PCRWR in the form of laboratories, equipped with requisite water sampling and testing equipment in each district of Punjab and Sindh;
• The bulk of the manpower will be provided by the provincial Govts. who will carry out the assigned tasks under the supervision of district PCRWR representatives;
• NGOs will also work under the supervision of PCRWR; and • PCRWR offers to provide technical support to NGOs working on ARTs.
3.3.8.2 Provision of Financial Resources
Financial Resources will be provided as below:
• A sum of Rs. 60 million per year will be allocated with Ministry of Science & Technology for exestuation of proposed arsenic mitigation plan;
• Provincial Governments will allocate Rs 30 million per year through PC-1 approved by the Provincial Governments;
• UN donor agencies will contribute 20 million per year; and
• Leading research institutes and technical universities to divert research funds in the field of water quality management, particularly in arsenic mitigation.
23
Table 3.3: Summary of Cost by Annual Phasing
(Rupees in Million)
Annual Phasing Component / Activity
2007 2008 2009 2010 2011 Total
Hydrogeological Investigation, Screening and Water Quality Monitoring
Sub Total 9.40 9.75 12.41 4.22 4.22 40.00 Mitigatory Measures (Including Social Mobilization, Capacity building, etc.)
Provision of Alternative Water Supply
30.00
40.00
40.00
45.00
45.00
200.00
Treatment of Arsenic Contaminated Water 40.00 50.00 50.00 55.00 55.00 250.00
Sub Total
70.00
90.00
90.00
100.00
100.00
450.00
Diagnosis of Arsenicosis Cases
1.60
2.10
2.10
2.10
2.10
10.00 (Including symptoms, clinical tests, identification, staff training, treatment of patients, food chain analysis, etc.) Development of Arsenic Removal Technologies
4.00
4.00
4.00
4.00
4.00
20.00
(Including household water treatment and development of potable water technologies at community level)
Impact Evaluation and Research
2.00
2.00
2.00
2.00
2.00
10.00
Total
87.00
107.85
110.51
112.32
112.32
530.00
Price Contingencies @ 5.0 percent / year
4.35
5.39
5.53
5.62
5.62
26.50
Overall Total
91.35
113.24
116.03
117.94
117.94
556.50
24
Chapter 4. MONITORING AND IMPACT EVALUATION
4.1 MONITORING AND EVALUATION PLAN
Monitoring and evaluation constitutes an essential part of the National Action Plan for Arsenic Mitigation. To carry out the monitoring of proposed components of action plan, the following steps will be undertaken:
a. Establishing a National Forum for Arsenic Mitigation at national, provincial and district levels;
b. Setting up of monitoring units at national, provincial and district levels;
c. Establishment of Data base unit for NAPAM activities;
d. Strengthening and expanding the scope and role of existing Water Quality Management and Information System (WQMIS) of PCRWR and its coordination, if possible, with other district information systems to avoid a top-down approach;
e. Improving the mechanisms and capacity of district governments for effective supervision, monitoring and evaluation of Arsenic Mitigation Programmes and projects;
f. Establishing coordinators at district levels for timely and speedy coordination among the various executing agencies;
g. Establishing Village Arsenic Mitigation Committees (VAMC) for enhancement of community participation, resource mobilization, monitoring and evaluation at the grassroots level;
h. Indicators for monitoring will be developed such as behavioural change on use of arsenic – safe water, improved sanitation and hygiene on washing hands with soap etc; and
i. The monitoring will also identify the problems and constraints during programme implementation, solution/supports provided by communities, and local government.
4.2 MONITORING AGENCIES
In order to monitor and evaluate the progress of work under the National Action Plan for Arsenic Mitigation, a project monitoring unit (PMU) will be established at PCRWR office Islamabad. Director (WQ) PCRWR and Chief Water and Sanitation UNICEF, will oversee the functioning of PMU.
a. PMU will monitor the execution plan/activities in the field and will ensure their timely completion in stipulated time and space;
b. National Steering Committee for Arsenic Mitigation will monitor, evaluate and review the arsenic mitigation programmes and work of PMU and will
25
hold quarterly progress review meetings under the chairmanship of chairman PCRWR; and
c. The PCRWR will monitor the existing technologies being used in the field for efficiency and provide the technical support in all the project areas.
4.3 ENVIRONMENTAL AUDIT
A central Technical Environmental Audit Team (TEAT) will be formed under the supervision of Director (WQ) PCRWR; other members will be nominated in consultation with DGLGs/CE (PHE). The envisioned task of the TEAT is:
a. Ensuring adherence to technical procedures by the sampling/testing/survey teams;
b. Verification of sampling strategies;
c. Ensuring compliance with work plans;
d. Ensuring judicious use of resources;
e. Ensuring correct data recording, compilation, collation and analysis; and
f. Checking and ensuring operational functioning of costly laboratory equipment.
4.4 SUBMISSION OF PROGRESS REPORTS
The following progress reports will be submitted by the PMU to the Steering Committee:
a. Weekly progress report at tehsil headquarters level;
b. Fortnightly progress report at provincial level; and
c. Monthly progress report will be submitted to administrative management (federal level) with a copy to all the tiers of management in the chain.
26
A C R O N Y M S
AAS Atomic Absorption Spectrometer ADLG Assistant Director Local Government ART Arsenic Removal Technology EDO Executive District Officer DO District Officer EPA Environmental Protection Authority GIS Geographical Information System GSP Geological Survey of Pakistan HHT Household treatment HRDS Human Resource Development Society HSA Health Services Academy IPH Institute for Public Health LG&RD Local Government and Rural Development MCLG Maximum Contaminant Level Goal MoH Ministry of Health NCCWS National Coordination Committee on Water and Sanitation NEQS National Environmental Quality Standards PCRWR Pakistan Council of Research in Water Resources PCSIR Pakistan Council of Scientific and Industrial Research PEPC Pakistan Environmental Protection Council PHED Public Health Engineering Department PM&EC Planning Management and Evaluation Cell ppb parts per billion SAFWCO Sindh Agricultural and Forestry Workers Coordinating Organization SDO Sub-Divisional Officer SHED Sindh Health and Educational Development Society TMA Tehsil Municipal Administration TMO Tehsil Municipal Officer UNICEF United Nations Children’s Fund WAPDA Water and Power Development Authority WHO World Health Organisation
27
R E F E R E N C E S
• Ahmad, T. Kahlown, M. A. Tahir, A, & Hifza, R. (2004). “Arsenic an Emerging Issue: Experiences from Pakistan”, Paper Presented at 30th WEDC International Conference Vietiane, Lao PDR.
• IPH (2003). Prevalence of Arsenicosis due to Ingestion of Arsenic through Drinking Water: An epidemiological Survey from Seven Districts of Punjab. Institute of Public Health, Government of Punjab (Supported by UNICEF).
• PCRWR (2003a). Arsenic Contamination in Groundwater of Southern Punjab. PCRWR, Ministry of S&T, Government of Pakistan (Supported by UNICEF).
• PCRWR (2003b). Innovative Low Cost Arsenic Removal Technologies for Developing Countries. PCRWR, Ministry of Science & Technology, Government of Pakistan (Supported by UNICEF, Pakistan).
• PCRWR (2004). Arsenic Contamination in Groundwater of Central Sindh. PCRWR, Ministry of S&T, Government of Pakistan (Supported by UNICEF).
• Kahlown M.A. Aslam Tahir, and Hifza Rasheed (2005). Arsenic Removal Technologies, paper presented at Korean Academy of Sciences, Seoul, 12th to 16 Oct. 2005.
28
ANNEXURES
29
Annexure-A
Work Completed by PCRWR on three Options of Arsenic Removal Technologies
The ground water pollution caused by arsenic in South Asian countries especially India and Bangladesh has led to major environmental crisis of arsenic poisoning. In Pakistan, the intensity of arsenic contamination in water is not too much. However, the concentration of arsenic in groundwater of Southern Punjab (Multan, Bahawalpur and Rahimyar Khan Districts) and Central Sindh (Khairpur and Dadu Districts) has been observed through different water quality studies by PCRWR. Presence of excessive amount of arsenic in ground water of Punjab and Sindh provinces has attained great importance among the national and international agencies. Big Districts like Multan, Bahawalpur and Rahimyar Khan is a home for an estimated population of 3.1 million people. Major part of the affected population in above districts is in rural areas where the people are quite unaware of the health hazards of arsenic. In water, arsenic is tasteless, colorless and odorless even at higher concentration. The magnitude of complexities of the arsenic contamination makes it an extremely difficult problem to handle. Added to this, socio-economic background of the people of such areas is not very favorable to overcome this problem. Most of the Southern Punjab and Interior Sindh depends on groundwater for drinking, cooking and other domestic purposes.
Review of arsenic removal technologies available in the world have revealed that many technologies have been developed for the removal of arsenic with applicability at large municipal treatment plant or at community or household levels. All of the technologies for arsenic removal rely on a few basic chemical processes such as oxidation-reduction reactions, precipitation, adsorption and ion exchange, solid liquid separation, physical exclusion and coagulation. Based on these reactions or chemical process, main technologies developed for arsenic removal are Air-oxidation, chemical oxidation, alum coagulation, ion coagulation, sorption techniques using activated alumna, iron coated sand or ion exchange resins, membrane technologies such as Nano-filtration, Reverse Osmosis and Electro-dialysis. These technologies remove arsenic but somehow have few drawbacks i.e. economically not feasible, technologically not sound, energy dependent, post treatment required etc. In recent years, a tremendous amount of research has been conducted to identify novel technologies for arsenic removal particularly low cost and low technology system that can be applied in rural areas of Bangladesh where the problem of arsenic poisoning is alarming the human life. Considering the socio-economic background of rural and urban set up of people, following three options were proposed for the development of low cost arsenic removal technology:
i) Clay pitcher for household arsenic removal filter; ii) Gravity flow arsenic removal filter; and iii) Arsenic removal cartridge filter.
Using locally available materials assembled the arsenic filtration systems. All types of filtration systems were evaluated for a period of Six months based on the measurements of arsenic (total), major, minor and trace elements, pH, conductivity and flow rate. These low cost arsenic removal technologies based on filtration and adsorption processes were monitored for a period of six months to gauge their effectiveness in reducing the arsenic up to a “Safe” level.
Low cost arsenic removal technologies have been evaluated for the parameters like composition of pre and post filtered water, life of arsenic removal media, flow rates, trace element distribution,
30
microbiological effectiveness and estimated cost. Based on observations, it has concluded that clay pitcher arsenic removal filter is the most feasible technology with respect to arsenic removal efficiency, life of arsenic removal media, estimated cost as well as simplicity and easiness. Therefore, it is highly recommended to promote this technology in the arsenic affected areas with the collaboration and cooperation of national and international agencies.
Clay Pitcher Arsenic Removal
Filter Household Arsenic Removal
Filter Gravity Flow Arsenic Removal
Filter
One hundreds and eighty measurements for clay pitcher arsenic removal filter, whereas thirty measurements each for gravity flow arsenic removal cartridge system and arsenic removal cartridge filter were monitored. Each measurement indicated an amount of 10 liters per day of arsenic contaminated (300 ppb for clay pitcher and 100 ppb for others) water passed through the filter. In case of clay pitcher arsenic removal filter, arsenic concentration of filtered water remained within WHO guideline (10 ppb) up to one month with 300 liters of water passed and remained within PSQCA water quality standards (previous 50 ppb) with 1800 liters water passed as shown in Table 1.
Incase of gravity flow arsenic removal cartridge system and arsenic removal cartridge filter cut off point is observed approximately after 10th measurement from where concentration of arsenic acceptably exceeded from WHO guideline value (10 ppb) and an approaching to 30th measurements values exceeded from PSQCA standards (50 ppb) with 300 liters of arsenic contaminated water filtered (Table 1).
Compositions of filtered and unfiltered water for physical and aesthetic, macro-elements, trace and ultra trace elements were compared at the three stages of technology monitoring i.e. beginning, middle and end of experimentation. Analysis for eighty different parameters showed that values of physical and aesthetic parameters, most anions and cations such as Na, K, Ca, Mg, CL-, PO4
-, SO4-, NO3
-, HCO3+, CO3
-, etc. were found within safe limits of WHO guideline values. Whereas concentrations of silicon, strontium, phosphorus, zinc, manganese, aluminium, boron and rubidium were increased slightly but remained within safe limits from beginning to end of experimentations. Flow rates for various measurements were recorded and it was observed that in the beginning technologies developed were having higher flow rates and gradually decreased with time as given in Table 2. Flow rate is rather more important in case of clay pitcher arsenic
31
removal filters and may depend on holes drilled at the bottom of the vessel. There was a direct relationship found between number of holes and flow rate. Greater the number of holes, higher was the flow rate. Concentration of arsenic was monitored in water filtered from several clay pitchers having variable number of holes (1 mm) at the bottom. After many trials it was decided to have 10-12 holes of 1 mm diameter at the bottom of vessel.
Table 1. Arsenic Removal Efficiency of Technologies
Life of arsenic removal media was determined by analyzing filtrate as a result of passing water containing 300 ppb arsenic through the selected media. The results are presented in Table 3.
Table 3. Life of Arsenic Removal Media of Different Filters
MPN for total coliform and fecal coliform (E.coli) in the beginning and in the middle of the experimentation were found negative for all three technologies, whereas, the results at the end of experimentation with the clay pitcher arsenic removal filtration technology showed presence of total coliform and fecal coliforms, which may be because of accumulation of arsenic removal solid waste and decline in effectiveness of silver coated sand, whereas, the results of other two technologies showed absence of bacteria (Table 4 & 5).
32
Table 4. Microbiological Evaluation of Arsenic Removal Technologies (Before Filtration)
Before Filtration Clay Pitcher Arsenic Removal Filter
Monitoring of arsenic removal technologies showed that clay pitcher arsenic removal filter is more feasible technology. Also it doesn’t require water supply pipeline or area with no water distribution system. However, certain precautionary measures are highly recommended for this technology such as:
i) Great care should be taken for operation and maintenance of arsenic removal systems including regular discard of hot water and choking of pores in case of Clay pitcher arsenic removal technology and replacement of cartridges in other technologies; and
ii) Clay pitcher Arsenic removal Technologies should be placed in clean and dust free area.
Disposal of the arsenic contaminated solid waste produced by the low cost arsenic removal technologies is an important concern, as this waste can become a cause of arsenic contamination in the water. Therefore, it is highly recommended to treat waste before its disposal. Waste is
33
directly disposed to a prepared bed of cow-dung in a shallow hole dug in the ground. The microorganisms in cow-dung transform the arsenic to gaseous arsine and arsene is thus released into the surrounding air. Objectives of this project were to develop affordable low cost arsenic removal technologies. To achieve this objective all local material of affordable cost was used. Estimated cost of all the components used in arsenic removal technologies are given in Table 1. Estimate of every technology also include the overall replacement cost to ensure continuous use of technology by the residents having problem of arsenic contamination in their drinking water. Clay pitcher arsenic removal technology is found comparatively cheaper (Table 6).
Cost (Rs.)Pitcher (Mud) 1 100 Cooler (Mud) 1 150Plain Sand 2.5 kg 25Casting Iron 3 kg 24Media 3 kg 150Silver Coated Sand 2 kg 400
Sub Total - 849
1. Clay Pitcher Arsenic Removal Filter
Cost on Media/Cartridge Replacement
- 599
Gravity Flow Vessel 1 1700Media 500 gram 25
Sub Total 1725
2. Gravity Flow Arsenic Removal Filter
Replacement of Cartridge and Media - 1200Casing/Housing and other accessories 1 1000Cartridge + Media 500 gram 600
Sub Total - 1600
3. Arsenic Removal Cartridge Filter
Replacement of Cartridge and Media 600
34
Annexure-B
Recommendations of Seminars/Workshops
Recommendations of Provincial Seminar on Arsenic Contamination in Drinking Water in Punjab held at Lahore on April 12-13, 2004
The two day seminar-cum-workshop ended with the following recommendations:
• Defining & laying down a national policy for safe drinking water;
• Promotion of alternative safe water supply options;
• Promotion of treatment and testing technologies;
• Strong advocacy for leading role of federal, provincial and district governments and resource commitments;
• Establishing institutional mechanism at all levels;
• Legislation and policy development within a framework of sector policy on water supply;
• Coordination mechanism and technical groups;
• Sustainable water quality monitoring and surveillance system at various levels;
• Capacity building at various levels on arsenic mitigation including health aspects;
• Development of effective and sustainable behavioral change communication material and Programme with strong community participation component;
• Awareness raising at different levels;
• Resource mobilization for arsenic mitigation;
• Case diagnosis and management;
• Aquifer and water quality mapping;
• Research and development; and
• Human face to arsenic problem. In addition to the above the seminar recommended to set a guideline value of 50 ppb for arsenic concentration in drinking water for Pakistan instead of 10 ppb recommended by WHO for a transition period of 5 years. The guideline value could be lowered gradually once arsenic contamination is addressed in areas having concentration over 50 ppb. At present both technologies and financial resources are limited to meet WHO requirements. Secondly, most of developing countries including India, Bangladesh, Nepal and China etc. are following a guideline value of 50 ppb.
35
Recommendations of Technical Sessions of National Workshop on National Action Plan for Arsenic Mitigation held at Islamabad on
April 18-19, 2005 The details of Recommendations of Technical Groups of the workshop are as under:
GROUP 1: INSTITUTIONAL FRAMEWORK This group was headed by district Nazim Nawabshah, Mrs. Farial Talpur. After heated debates, the group put forward following recommendations ; Federal Level
• Secretary Science & Technology should be the Chairman; • Chairman PCRWR should be the Vice Chairman; • Director Generals of All the line departments and representative of provincial line
departments as well as from FANA/AJK should be included; • Let the provinces nominate their representative.
Provincial Level • Representative of PHED or LG should be the chairman as per requirement of
provinces; • All heads of line department like DGs, Chief Engineers etc. should be included; • Director General Environment should be included. • Similar structure in FANA/AJK
District Level • Nazim Chairman • DCO Vice Chairman • EDOs of all the line departments should be involved
GROUP 2: HYDROGEOLOGICAL The group was headed by Dr. Zaigam and suggested following:
• 10% samples from Balochistan, NWFP, FATA, FANA/AJK should be analyzed for arsenic presence;
• Surface and sub-surface water quality should be assessed to identify hot spot areas; • Detail investigation of hot spots should be conducted for all parameters in addition to
arsenic; • Institutional mechanism should put in place to regulate ground water pumping; and • Geological studies should be carried out up to basement of rock/alluvial and bed.
36
GROUP 3: SAFE DRINKING WATER SUPPLY The group was headed by Maulana Abdul Bari, provincial minister for environment, Balochistan. After thorough discussions, the group formulated the following recommendations to be incorporated into NAPAM, 2007-2011: Short Term
• Surface and groundwater should be surveyed and monitored of all left out districts; • All contaminated water sources should have alternate options available; • Implementation of national water quality standards should be enforced and
implemented; • Water treatment plant should be integral part of water supply systems especially in
urban areas; • New water sources be certified before opening for drinking for general public; and • PCRWR technologies should be analyzed and assessed by 3rd party and then it
should be made available to all.
Long Term
• Availability of drinking water to those who don’t have; • Rehabilitation of water supply and sanitation systems; • Provision of safe drinking water & sanitation should be provided to all; • Established of laboratories at Tehsil level; • Drinking water polity/clear water act should be put in place of natural level; • Policy of disposal of solid waste stocks, hospital and industrial waste; and • Clean program for all water sources.
GROUP 4: HEALTH
The group consisted of medical professionals and recommended the following for NAPAM, 2007-2011:
• Situation analysis regarding arsenic contamination levels and health effects in all districts of Pakistan;
• Develop training guides/educational materials; • Establishing and maintaining an efficient and effective and referral chain for clinical
arsenicosis case diagnosis; • Detection and reporting of cases should be implemented in the consideration of chain
of evacuation of casualty; • Training health workers as soon as possible in case detection; • Technical support to existing laboratories for epidemiological and diagnosis
investigation;
37
• Establishment of a multi-disciplinary, autonomous, International Centre for arsenic mitigation in Pakistan to act as centre of excellence for arsenic related research, quality control of technologies, and to oversee coordination of activities;
• Issues related to arsenicosis, both clinical and public health, should be incorporated into the curriculum of the medical institutions;
• Establishment of a multi-disciplinary National Task Force for the identification of arsenicosis and its causes, formulation of strategies to diagnose, treat, and prevent, and subsequent monitoring in order to effectively combat the menace of arsenic contamination; and
• Develop protocols on diagnosis and management according to stages of disease.
GROUP 5: SOCIAL MOBILIZATION The social mobilization group made following recommendations for NAPAM, 2007-2011.
• Community participation at district level headed by DCO, EDO (H), EDO (CD), EDDO (E) should be given key role;
• Orientation sessions/training at TMA level; • NGO/CBO/readers through mosque and others to be involved in social mobilization
and awareness training; • District and Tehsil Nazims should coordinate all activities; • Communities should be the prime motivators; • Balochistan and NWFP be included in the arsenic mitigation programme; • Removal technologies be installed at hand pump level; • Finance should not be funded through DCOs; and • Private sector should be effectively involved.
GROUP 6: FINANCIAL RESOURCES Recommendations put forward by financial group are as under:
• All provinces be included in the blankets testing programme; • Besides district level labs, mobiles labs. Be established; • Each district government & TMA should contribute at least 10% of funds provided
by Provincial Government; • Aid be sought from donor agencies for sustainability during & after the project life; • Direct release of funds to the concerned local government by the provincial
government; • Infrastructure to be developed during next 5 years programme be transferred to
concerned local government for sustainability; and • Identified pollutants like cotton industry be asked to make financial contribution.
38
GROUP 7: MONITORING & EVALUATION Monitoring and evaluation group suggested the following for inclusion in the NAPAM, 2007-2011:
• Include in-coordination with provincial departments; • Instead of TMA, separate project monitoring unit should be established at TMA level
with its branches at provincial and Distt. Level to monitor & evaluate the execution of the project;
• Instead of AD local Govt, AD P.M.U should monitor the progress of project; • Director PMU should monitor the progress at provincial level; • The head of PMU should be the member of National steering committee; • PCRWR in collaboration with PCSIR, EPA and PHED should monitor existing
technologies being used in the field; • Submission of progress on monthly and quarterly basis; and • Website.
SPECIAL TECHNICAL GROUP
A special technical group, comprising of highly technically sound and skilled experts, was constituted to examine the important chapters of the proposed national action plan (NAPAM, 2007-2011), specially the hydrogeological and geological aspects.
Special technical group recommended for:
• Immediate undertaking of soil investigations at various depths in the affected areas to ascertain the causes of arsenic contamination;
• Involvement of NED university, Sindh and UET, Lahore into hydrogelogical investigations;
• A workable proposal soon be submitted on the subject by this group to undertake hydrogeological investigations in Sindh;
• Transformation of existing arsenic contamination data on GIS; • Establishment of data base and collection infrastructure; and • Encouragement of geological postgraduate and PhD scholars for undertaking on job
project in the field.
CLOSING SESSION Closing session was chaired by Ch. Nouraiz Shakoor Khan, Federal Minister for Science and Technology. This session was attended by the following dignitaries:
• Maulana Abdul Bari, Provincial for Environnent, Balochistan; • Makhdoom Ashfaq Ahmed, Provincial Minister for Environment, Punjab; • Group captain ® Mushtaq Ahmed Kiayni, Provincial Minister for PHED, Punjab; • Mr. Omar Ahmad Abdi, Country Representative UNICEF, Pakistan;
39
• Mr. Holiang Xu , Deputy Country Representative UNDP, Pakistan; • Dr. Mohammad Akram Kahlown, Chairman PCRWR; and • Mr. Mohamed El-Fatih Yousaf, Chief (WES) UNICEF, Pakistan.
Dr. Mohammad Akram Kahlown, Chairman PCRWR, presented the final recommendations of National Action Plan for Arsenic Mitigation (NAPAM, 2007-2011). Maulana Abdul Bari, Provincial Minister for Environment, Balochistan
Commented on the scarcity of safe drinking water in the province and stressed the need of undertaking mega project for the provisioning of sufficient water for irrigation and drinking purposes.
He also gave the detailed account of district wise water shortages situation in the province. He requested the honorable Federal Minister for Science and Technology to ear mark special funds for development of deep wells in the province and establishment of water testing laboratories for monitoring of existing water sources. He assured the house that his Government will implement the recommendations of the NAPAM, 2007-2011 in true letter and spirit.
He thanked the organizers for holding such an important workshop on safe drinking water, which is first of its kind in the country. Makhdoom Ashfaq Ahmed, Provincial Minister for Environment, Punjab He lauded the efforts of the federal government for paying special attention for provisioning of safe drinking water. He remarked that government of Punjab will extend full support for the implementation of the national action plan for arsenic mitigation and will also contribute its share to fulfill the financial obligations. He also presented few recommendations which are as under:
The Plan suggests following areas to be developed further:
o Hydro geological; o Health; and o Safe Water Supply.
Institutional policy and Legal Frame Work
o The above areas will be supported by following cross cutting themes:
• Strong communication for behavioral change; • Community mobilization; • Capacity development; • Resource allocation; and • Monitoring and surveillance.
The Plan also allocates an estimated financial resource of Rs.520 Million for over five years. Federal, Provincial, donors and development partners including private sectors, civil societies will work in coordination and with concerted efforts to achieve the envisaged goals.
40
Additional efforts have to be undertaken on the following specific areas:
• Research; • Case diagnosis and management; • Aquifer mapping and water quality monitoring; • Expansion of arsenic screening to other districts; and • Development of community based water quality monitoring and surveillance system.
The whole plan is an integral part of the overall provision of safe drinking water initiative of the government to achieve Millennium Development Goals (MDG), Poverty Reduction Strategy Policy (PRSP), and other national and international targets and commitments.
Appropriate processes which are in line with the government devolution policy must be followed for provision of safe drinking water.
Coordination mechanism at federal, provincial and district level must be put in place as proposed in the action plan.
The proposed safe drinking water policy should incorporate all the provisioning of this action plan. Group Captain (R) Mr. Mushtaq Ahmed Kiayni, Provincial Minister for PHED, Punjab He thanked the Federal Minister for Science and Technology and organizers of the workshop for enlightening the masses about the deadly contaminants found in the drinking water. He announced that he will try to get maximum funding from the Punjab Government for making arsenic free drinking water.
He also intimated that his ministry already working on a plan for installation of water filtration plant in the whole of the province. Dr. Omar Ahmad Abdi, Country Representative, UNICEF Pakistan
Water is the lifeblood of the environment, essential to the survival of all living beings. Safe drinking water is vital for people’s health and poor quality drinking water can create health risks. National Water Quality Monitoring Program implemented in 23 major cities by PCRWR has revealed the prevalence of four major contaminants in drinking water such as bacteriological, arsenic, fluoride and nitrate.
In Pakistan, arsenic contamination is one of the emerging issues due to serious health concerns. Arsenic in drinking water poses considerable threats to human health as it can cause or aggravate the various types of cancers of the lungs, bladder, skin, prostrate, kidney, nose and liver. In this regard, PCRWR and UNICEF have undertaken many initiatives since 1999. These initiatives include arsenic monitoring as well as mitigation efforts. According to findings, the arsenic problem is comparatively intense in the districts of Central Sindh and Southern Punjab. Consequently, domestic and community level arsenic removal technologies were successfully developed and promoted in hundred girls primary schools of Sindh and Punjab with the financial assistance of UNICEF and UNDP to safeguard the public health. However, aforementioned efforts are not sufficient to address the whole issue.
41
There is dire need to integrate all the efforts carried out by government organizations, Non- government organizations and international agencies. Furthermore, to arrest this unwanted issue two provincial workshops (Punjab and Sindh) were organized to sensitize the public and implementing agencies.
He assured the federal minister for further financial and technical assistance in fulfilling the noble objectives of the five year National Action Plan for Arsenic Mitigation, (NAPAM, 2007-2011).
Mr. Holiang Xu, Deputy Representative UNDP, Pakistan
In his closing remarks, he lauded the efforts of government of Pakistan, particularly, ministry of science and technology for arranging such a gathering of experts to brain storm the crises of water contamination. He highlighted the importance of clean drinking water for the entire population of Pakistan. He also mentioned the installation of arsenic removal technologies (ARTs) in 100 schools of Punjab and Sindh with financial help of UNDP. This he said, just a start, we all go all out to help Pakistan for improvement of this human problem by installing more Arsenic Removal Technologies (ARTs) every where in Pakistan.
He further added that UNDP will continue to support such programme in future also and you will find us one step ahead of every body.
Finally, he thanked the honorable minister and all the organizers for arranging such an informative event and extended invitation to me.
CLOSING ADDRESS Ch. Nouraiz Shakoor Khan,
Federal Minister for Science and Technology Makhdoom Ashfaq Ahmed, Minister for Environment, Punjab, Moulana Abdul Bari, Minister for Environment, Balochistan, Dr. Muhammad Akram Kahlown, Chairman, PCRWR, Ladies and Gentlemen
It is a matter of great pleasure for me to participate in the final session of two days National Workshop on National Action Plan for Arsenic Mitigation in Pakistan. This topic has direct bearing on millions of lives of the residents of the country especially Southern Punjab and Central Sindh. I would like to take this opportunity to thank you for attending this workshop and making contribution in the finalization of Arsenic Mitigation Plan.
I am briefed that during the two days, the participants discussed the various aspects of arsenic monitoring and mitigation and made many suggestions in the draft National Action Plan for Arsenic Mitigation in Pakistan. National Action Plan provides the direction to control this issue and integrate all efforts made so far by different agencies. The frame work of this plan is very comprehensive as it covers almost all aspects including hydro geological, alternate safe water supply, health, policy, institutional framework, research, capacity building, community and resource mobilization. The goals and targets set in the plan are in line with Millennium Development Goals, Government National Water Strategy, Poverty Reduction Strategy Paper and other national and international commitments. This finalized plan in fact reflects the Devolution Support Program to eradicate the poverty. As we are not only concerned with integrated water management, but our principal goal is provision of “Safe drinking water for all”.
42
Personally, I am thankful to the experts and participants for their useful feedback and recommendations to finalize the draft National Action Plan. I would like to assure you that all these recommendations would be incorporated in the plan for implementation. I fully support the proposed National Action Plan and reiterate full support on behalf of Ministry of Science and Technology, Government of Pakistan for its implementation.
I like to conclude by thanking the organizers and participants of the workshop, who came from distant areas to join this important workshop and wish that the revised National Action Plan would soon be implemented through active participation of all the stakeholders to achieve the desired goals and targets.
MEDIA BRIEFING- SESSION After the closing address by the Honorable Minister for Science and Technology, the media was invited and apprised of the situation of groundwater pollution. Ch. Nouraiz Shakoor Khan gave brief resume of the drinking water status in Pakistan and the efforts and priorities of his Government to this basic human problem.
The honorable minister revealed that we will be able to provide clean drinking water to our people in the next three to four years in the light of prim minister’s directive. If could do so, then our hospitals might get emptied from the patients, as 80% diseases are due to contaminated water. The Preliminary findings were also shared with them. by Makhdoom Ashfaq Ahmed, Mr. Mushtaq Ahmed Kiayni and Mualana Abdul Bari provincial ministers of environment Punjab and Balochistan, delineating the responsibility of the media emphasized that they were looking upon the media to highlight the issue accurately and not blow it out of proportion. “Governments, NGOs and the medical profession have a lot of faith in the power of media in spreading awareness about arsenic. In fact, it is through the media coverage that the policy-makers can be made more sensitive to the issue. However, if media is not a part of the solution, then they become part of the problem. While the media cannot bring about a change overnight, a wrong message can cause incalculable damage and set back years of work in advocacy. It is important to first be informed and then inform,” he said adding that the issue is a complex one as there was no pattern to this contamination that could be followed.
Dr. Omar Ahmad Abdi, country representative, UNICEF, told the journalists that regular use of arsenic polluted water, over a long period of time can cause an unacceptably high concentration in the human body, leading to the onset of various diseases, including skin rashes, cardiovascular ailments and even cancer. The problem cannot be detected as the element is colorless as well as odorless. Mr. Mohamed El-Fatih Yousaf, chief (WES) UNICEF, apprised the journalists about the role of WES program for making arsenic free drinking water.
Dr. Mohammad Akram Kahlown, Chairman PCRWR, gave the detailed briefing about developing Arsenic Removal Technologies (ARTs). He also mentioned the successful installation of these ARTs in 100 schools of Punjab and Sindh. He assured the journalists that ministry of science and technology has laid top priority for provisioning of clean drinking water to the people within the stipulated time frame work.
Gentlemen, with this encouraging attitude by my ministry, I can assure you that PCRWR, will be able to achieve the objectives and directives of the prime minister of Pakistan for provisioning of clean drinking water to people within four to five years time. He further said that this very workshop was the first step towards achieving our aims.
43
Lt. Col. (R) Mohammad Shahbaz, DGLG, Punjab spoke on the occasion and solicited support of the media in creating awareness among people about ways and means to mitigate the same. He also talked about the four-part integrated approach that UNICEF was undertaking namely communication for awareness, blanket testing of tube wells and hand pumps, patient identification and safe water options. He also gave the latest arsenic status in the province of Punjab.
Journalists enquired about the content of arsenic in the water supplied major towns. To that Mr. Mushtaq Ahmed Kiayni, assured the media that problem of arsenic contamination in water supplied to the population was not there as the poison was detected in groundwater and the water supplied to most of the cities is surface water. He, however, admitted that some hydrants in the cities were supplying contaminated water and those needed inspection.
Apprising the media, Mr Mohamed El- Fatih Yousaf, UNICEF, said the problem of arsenic contamination was a particularly complex one. During their campaign in Bangladesh, he said, they came across villages where one well would have contaminated water while a few yards away another one would have perfectly safe water. Blanket and continuous testing, he stressed, was the only way of resolving the problem. He, however, warned that safe water wells, at times, can get contaminated.
At the end, Ch. Nouraiz Shakoor Khan was of the opinion that the government should take everyone along if theirs was going to be a success story. The role of NGOs, opinion leaders and village committees in community mobilization has always been immense, he argued, and cannot be undermined. He said the day had given food for thought to the government as well as given it some direction to take the process forward.
The Honorable Federal Minister thanked the media person for their keen interest and hoped that they will join us in creating awareness among the masses on positive node.
44
Annexure-C
Map of Arsenic-Affected Districts
45
Annexure-D
Other Relevant Details of PCRWR Project 1. Promotion of Low Cost Field-Testing Kit for Arsenic A low cost kit for arsenic determination has successfully been completed in 2003-04 to provide a convenient way to non-scientists to check arsenic contamination in their drinking water using simple test. Low cost arsenic field-testing kit is a great break through with a minimum detection limit of 1 ppb. These kits are also under manufacturing stage in bulk to be promoted in arsenic affected areas.
Low-Cost Field Testing kit for Arsenic
2. Status of Arsenic in Groundwater of Punjab (Phase-II): PCRWR with the financial support of UNICEF in 2003-04 undertook detailed testing of arsenic in Punjab particularly in Bahawalpur, Rahimyar Khan and Multan Districts to confirm the arsenic contamination. In total 2395 samples were analyzed on Atomic Absorption Spectrometer. Out of 2395 water samples, 543 samples (22.67%) were found to be having arsenic concentration above the WHO guidelines (10 ppb) and only 67 water samples (2.79 %) were found beyond 50 ppb limit. As second phase, blanket survey was conducted in already monitored districts as well as surrounding districts to evaluate the status of arsenic in drinking water sources. Out of total eight districts 2216 samples have shown about 41% above 10 ppb and 15% beyond 50 ppb as shown in following table.
Total 20 200 2216 905 346 40.83 15.61 Note: Projects successfully completed and report has been submitted to UNICEF.
46
3. Promotion of Low Cost Arsenic Removal Technologies by PCRWR
Arsenic free water is urgently needed for immediate protection of health of the people living in arsenic affected areas of Punjab and Sindh. A lot of technologies for the arsenic removal from drinking water are already present. However, UNICEF has sponsored to make efforts to develop a low cost water treatment unit which eliminates not only arsenic but also removes microbiological contamination.
Clay Pitcher Arsenic Removal
Filter Household Arsenic Removal
Filter Gravity Flow Arsenic Removal
Filter
Three options such as Clay Pitcher Arsenic Removal Filter, Gravity Flow Arsenic Removal Cartridge Filter and Arsenic Removal Cartridge Filter were designed and monitored for its efficiency to remove arsenic in the water. Evaluation of arsenic removal technologies showed that clay pitcher arsenic removal filter is more feasible technology. After successful evaluation these household filters are being promoted in the arsenic affected regions of Punjab in collaboration with UNICEF.
4. Status of Arsenic in Groundwater of Central Sindh (PHASE-II):
Arsenic monitoring in Khairpur and Dadu districts of Sindh province was initiated by PCRWR in 2003-04 collaboration with UNICEF. In total 20158 samples from 6 tehsils of district Khairpur and Dadu were collected and 10% of the samples were analyzed on Atomic Absorption Spectrometer by PCRWR.
Comparison with WHO and PSQCA limits for arsenic in drinking water revealed that 36% of samples exceeded WHO guideline value (10ppb) and 16% samples were beyond PSQCA standard for arsenic (50 ppb). The second phase of the same monitoring project was carried out in 2004-05 in the three districts of Sindh i.e Dadu, Khairpur Mirs and Tharparker. In total 2837 samples were collected out of which about 21% and 8% exceeded 10 ppb and 50 ppb respectively as shown below:
Keeping in view the possible health implications of arsenic poisoning in the two provinces of Pakistan, PCRWR has initiated another project entitled “Arsenic Monitoring and Mitigation in Pakistan” with a total cost of Rs: 35.8 million for a period of three years. Objectives of the project are as following:
1. To conduct prospective survey for arsenic contamination in Punjab and Sindh province of Pakistan and undertake blanket/ screening survey in the affected areas.
2. To provide low cost arsenic removal technologies developed by PCRWR in the affected areas. 3. To conduct research for the identification of the causes of arsenic in ground water and develop
solutions. 4. To establish small-scale arsenic analysis labs in the affected areas and to disseminate
information among end-users by print and electronic media.
One year work plan for the year 2007-2008
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr Activity
1 2 2
Identification and setup of monitoring network in project areas Detailed blanket testing and screening of water sources
Collection of samples
Field testing of samples
Laboratory analysis of samples
Study design for root cause identification (Geochemistry & Hydrogeology) Initiation of field activities for study of Geochemistry & Hydrogeology
(Continued)
48
(Contd) Differentiation of water sources by colors Arrangements of low cost arsenic removal techniques developed by PCRWR Provision of low cost arsenic removal techniques developed by PCRWR Processing and analysis of data
49
Annexure-E
Screening of Water Sources - Protocols
Guiding Principles
1. Sampling unit will be taken as union council. There are total 5994 union councils in entire Pakistan and each district has different measurement of area in one union council.
2. Sampling density will be taken as one sample per 4 x 4 km. Reliable testing facilities should also be available to institutions, organizations and individuals at a reasonable cost to undertake such surveys.
3. Survey work primarily will be carried out by local government under the technical supervision of PCRWR. Quality control of field surveys is essential for which Reference Laboratories to validate field test results be established on a priority basis.
4. Sample preservation will be carried out by adding 1% concentrated HCL as sample preservative.
5. Six Laboratory Facility units, two each in Punjab and Sindh and one each in NWFP and Baluchistan will provide technical support.
6. The process of survey of existing water sources to be accelerated and screening of all the tubewells, wells both hand pumps and irrigation wells be undertaken on priority basis in highly-contaminated/high risk areas.
7. Capacity development of non-technical staff will be carried out prior to commencement of sampling work.
8. TMO (Tehsil Municipal Officer) will be responsible for provision of all administrative and logistic support to the sampling staff.
Methodologies – Participatory Implementation
1. Community participation will enhance the efficiency of survey manifold, therefore involvement of the community will be sought after imparting planned capacity development programme and proper training.
2. Composition of sampling party will be three individuals from local government and one individual ex-PCRWR (1 + 3).
3. Integrated sampling parties will also be tailored from the local community, preferably from schools and colleges.
4. The latest and up-to-date map of each district will be obtained from survey of Pakistan showing all the details of communication infrastructure, demography, hydrological aspects of the area.
5. The map will be divided into 4 x 4 km grid (the sampling density).
6. Representative sampling will be ensured for each geological unit.
50
7. A minimum of two km distance will be maintained between two sites, except where different aquifers were sampled.
8. Approximately 10 % of all the sites will be selected for cross-analysis for the second laboratory and one site in each district will be earmarked for replicate sampling.
9. 10 % of samples will be sent to PCSIR for cross verification as a tool of external quality control.
Analytical Procedures – for Determining Arsenic (for lab staff)
1. If total arsenic is to be determined, the first step usually consists of complete mineralization. The arsenic can then be measured directly by, for example, flame or graphite tube atomic absorption spectrophotometer (AAS). In an ordinary flame, the detection limit is 0.5-1 mg/litre. Using a long-path cell, a detection limit of a few.
2. µg/litre can be obtained.
3. The most commonly used techniques for the determination of arsenic involve its transformation into arsine. Subsequent measurements of arsine can be carried out using, spectrophotometer, flames and electro thermal devices for AAS, atomic fluorescence spectroscopy (AFS), or atomic emission spectroscopy (AES).
4. Spectrophotometry of the silver diethyldithiocarbamate complex of arsine has been used for several years, and is suitable for determining arsenic levels in the range of 1–100 µg. Passing the arsine generated, for instance, by sodium borohydride, into a heated tube of an AAS or AES instrument gives an absolute detection limit of about 0.5 ng. If oxidation can be avoided prior to the arsine generation step, it is possible to differentiate between As (III) and As (V) by changing the pH value at this step.
5. Furthermore, cold trapping of the arsines and separation upon heating can be used for the separation and detection of inorganic and methylated arsenic compounds present in natural waters and urine. Other separation methods include ion exchange chromatography, gas chromatography, and liquid chromatography.
6. Neutron activation analysis using radiochemical separation is a very sensitive method for the determination of arsenic, with detection limits near 1 mg.
51
Annexure-F
The Geological Survey – Survey Protocol
1. Geological Survey Maps are available with the Geological Survey of Pakistan and other departments such as Water and Power Development Authority (WAPDA). Geological Survey will assist in determining:
a. The cause of arsenic contamination;
b The exact or probable sources responsible for arsenic contamination; and
c. Mobility phenomenon of arsenic in the groundwater.
Joint Venture Programme – Organizations to be Tapped
2. The following organizations, private entrepreneurs and institutions will be involved and consulted:
a. Geological Survey of Pakistan;
b. Geological departments of technical and engineering universities;
c. Water and Power Development Authority (WAPDA);
d. Private sector entrepreneurs; and
e. Irrigation Department.
Methodologies - Programme Implementation
3. The following procedure and programme will be adopted and implemented:
a. Formation of a coordinating committee under the supervision of DGLGs of the provinces for coordination with these departments;
b. Dissemination of required geological information to the survey teams;
c. Collection of arsenic-related data;
d. Detection of contaminated and arsenic free aquifers to advise concerned organizations regarding alternative arsenic-free groundwater supplies;
e. Exchange of views and data nationally and internationally;
f. Promotion of awareness among general populace about arsenic poisoning;
g. Mapping, identification and testing of all arsenic affected tubewells in the operational area villages, in collaboration with local governments;
h. Collaboration with PHED/Local Government and other agencies in the designing and testing of alternative containers and reservoirs for use as viable arsenic-free water supplies;
i. Testing of different options for safe water catchments;
j. Exchange of information and collaboration with other partners;
52
k. Rainwater Harvesting (cum sand filter-treating arsenic contaminated tubewell water in the dry season);
l. Development of capacity of NGOs to provide support and technical assistance to field staff;
m. Multi-channel dissemination of information and to reinforce efforts of the various agencies working for arsenic mitigation and social mobilization;
n. Preparation of up-to-date geological maps, particularly of arsenic carrying types of sediments; and
o. Developing the GIS (Geographical Information System).
53
Annexure-G
Alternative Water Supply - Protocol General
The alternative water supply activity is based on the following facts and assumptions:
• The alternative technologies are area dependent and cannot be prioritized for the whole country;
• The country is broadly divided into shallow water table areas, low water table areas, coastal saline areas, mountainous areas requiring technological variations;
• No single option can serve the purpose of people having different social & economic conditions;
• Choice of the communities should be given priority in the selection of technological options; and
• Illiteracy and knowledge gaps in some areas will impede decision making regarding selection of alternative technologies for arsenic affected areas.
Alternative Water Supply Options
Despite many constraints the following alternative water supply options are suggested/ recommended:
Emergency
In acute arsenic problem areas, an appropriate alternative safe water point is to be provided in each village on an urgent basis following ongoing national screening program.
Short-term
• Deep Tube well (where suitable aquifer is available).
• Dug/Ring well (where technically feasible).
• Rainwater harvesting.
• Treatment of surface water (adequate quality and quantity).
• Treatment of arsenic contaminated water.
Long-term
• Proven safe and sustainable technologies implemented under short-term options.
• Piped water supply.
54
Site Specific Selection of Options
The possible sites for different alternative technologies are given below:
Deep Tubewells
Manually operated deep tubewells are sources of safe and reliable water supply in many parts of the coastal area. In other areas, safe deep aquifers may be available to produce water of acceptable quality for water supply.
Requirements
• It is important to first delineate the areas where such deep aquifers that are separated from shallow contaminated aquifers by relatively impermeable layers are available.
• The annular space of boreholes of the deep tube wells are required to be sealed at the level of impermeable strata to avoid percolation of arsenic contaminated water.
Dug/Ring Wells
Dug wells may be constructed where feasible for arsenic safe water supplies. The areas with aquifers at shallower depth and the hilly areas are suitable for construction of dug wells. The areas with thick consolidated clay layers are not suitable for dug well construction. There should be a sanitary protection and provision for disinfection of dug well water.
Caution
Dug/ring wells are to be tested in an acute arsenic problem area for arsenic content under following conditions:
• Continuous withdrawal of water for few days.
• Complete sanitary protection.
• Contamination from on-site sanitation.
Rainwater Harvesting
Rainwater harvesting has good potential for water supply in arsenic and salinity affected areas. It is suitable in the areas with high rates of rainfall.
Requirements
• Standardization of catchment areas and storage tanks in relation to rainfall intensity and distribution.
• Monitoring of water quality, particularly during the dry period.
55
Surface Water Treatment
Treatment of surface water can be an option in any part of the country having perennial surface water of adequate quantity and of good quality. Flowing rivers, reservoirs, lakes protected ponds are preferred sources. The technologies include:
• Slow Sand Filters/Pond Sand Filters (PSFs).
• Pressure filtration followed by disinfection.
• Small-scale conventional or prototype treatment plants.
• Conventional surface water treatment plants.
Requirements
• Removal of impurities of any health concern.
• Desired level of clarification and disinfection.
Treatment of Arsenic Contaminated Water
Some units developed (PCRWR - HHT) for treatment of arsenic at household and community levels and installed for experimental use in Rahimyar Khan district, etc. have shown very good potential for use in water supply in all arsenic affected areas.
• Centralized arsenic removal plant for urban water supply is possible.
• In period of scarcity, arsenic treated water may supplement other sources.
Caution
• Protocols for management of sludge and wastewater rich in arsenic need to be developed.
• Validation of technologies is essential prior to mass scale use.
Piped Water Supply
Piped water supply is the long-term objective. In an urban center with piped water supply, the people dependent on shallow tubewells can rapidly be brought under piped water supply through expansion of existing areas of service coverage. Piped water supply should also be introduced in the urban centers fully dependent on contaminated shallow tube wells. Arsenic removal would be required for the few urban centers having arsenic contaminated production wells.
Piped water supplies are also possible for clustered households in villages, growth centers and the rural areas having good rural road network.
Arsenic-safe water for piped water supplies may be available from sources such as deep tube well, treated surface or arsenic contaminated water or water from community dug wells.
56
Monitoring and Surveillance
Performance and quality of water of the existing safe tube wells and the proposed short-term options need regular monitoring and surveillance.
Institutional Arrangements for Implementation of Alternative Water Supply
Vision Statement
Safe and adequate amount of water will be provided for drinking and cooking in all households through effective, efficient and sustainable institutions. Services will be provided and managed locally, in a manner that is transparent and accountable. National interests and public goods issues will be addressed by the Federal Government.
Role of the Federal Government
• A national legislation for water quality and supply for regulation, monitoring and implementation should be developed. National Water Council must play an important role in this process.
• The regulatory capacity of PHED to provide technical guidance and monitoring for supply of safe water should be strengthened.
Role of Local Government
• The government policy of decentralized provision of services related to safe water options through Union Councils (UCs) should be operationalized immediately. This will lead to a much closer involvement of local government in the implementation of safe water options.
• UCs should also be involved in mobilizing resources, monitoring and information management, and, more specifically, registration of tube wells can be undertaken by the UCs.
Role of Communities and NGOs
• Local communities must be empowered to undertake planning, implementation and management of safe water options. Planning in the community should be based on informed choices. NGOs must play a vital role in this process.
• There should be a strong focus on capacity development at the local and/or community level for technical implementation and monitoring.
• Formation of user groups for local implementation and monitoring should be encouraged throughout the country with support from NGOs and local governments.
Role of the Private Sector
• The private sector can play a key role in implementation of safe water options and interacting with the end users. This role should be reflected in the national policy for provision of safe water options and development of innovative, enterprising solutions should be encouraged.
• Involvement of private sector in financing of well monitoring and safe water options should be encouraged through tax relief and other incentives.
57
Capacity Development
• Institutional capacity development for the regulatory functions and monitoring should be undertaken by the Central Government (Ministry of Local Government).
• Capacity development at the local and community level should include technical capacity for installation, operation & maintenance, and monitoring should be a key element of the national policy. This should also include the capacity for information management and reporting.
Information Management and Applied Research
• Knowledge and information should be managed centrally to ensure transparency of the implementation process. Ready accessibility of information to all stakeholders is essential. Governmental institutions, PCRWR, PCSIR and technical universities should accept this sustained role of functioning as an information warehouse at the national level.
• Centers of excellence for relevant research on safe water options should be developed. These centers should focus on existing information and knowledge leading to identifying and conducting research on key areas.
Task Force
A Task Force led by PHED may be constituted to undertake prioritizations of safe water options and develop strategies for their implementation.
The Task Force should focus on:
• A clear time frame for implementation;
• The formulation of a protocol that includes technological and socio-economic criteria; and
• A strategy for information management and dissemination.
The Task Force will formulate the roles and responsibilities of the ministries, departments and directorates, local government institutions, research institutions, private organizations, NGOs and CCBs.
The information emerging from the Task Force should be adequate for making informed choices by communities.
Research and Development
There are many areas of research and development in diverse fields of alternative water supplies. Some of the areas of research are listed below:
• Leaching characteristics of arsenic-rich sludge under different conditions and possible contamination from arsenic-rich effluents produced by arsenic removal technologies;
• Development of construction, operation and maintenance manuals for each of the following: rainwater harvesting, dug wells, water treatment plant, piped water supply;
58
• Effect of sanitary protection on arsenic content of dug well water;
• Development of an accurate and reliable field kit for measurement of arsenic at the village level;
• Development of effective, affordable and environmentally friendly arsenic removal technologies for use in rural areas;
• Analysis of water supply situation including population exposed to arsenic contamination based on updated data available from on-going studies and national screening program;
• An evaluation of effectiveness, impact and reliability of arsenic mitigation initiatives; and
• Study of water treatment plants in operation in the entire country for the identification of problems and possible solutions for application in the design of alternative water supply technologies.
59
Annexure-H
Sample Protocols
I. Arsenicosis Diagnostic Protocol
1. The guidelines for diagnosis of arsenicosis are based upon symptoms of skin lesion manifestation. The diagnostic symptoms are categorized as under:
Fundamental Diagnostic Symptoms Index
a. Hyperkeratosis on the palm and soles (causes are still to be elucidated). b. Hyper – pigmentation and or hypo–pigmentation that emerges on the skin of the
unexposed body areas (causes yet not established). Referential Diagnostic Symptom Index a. Peripheral neuritis, i.e. sensory and motor polyneuritis and myophagism (causes
not yet known). b. Arsenic levels in urine or hair samples are significantly higher than the normal
levels in non-epidemic areas of the same region. 2. DERMATOLOGICAL – METAMORPHOSIS CLASSIFICATION Hyperkeratosis on the Palms and Soles
a. Scattered corn like nodular hyperkeratosis on the palms and soles that are visible to the naked eye and can also be detected by pressing with the thumb.
b. More and larger distinct papulous like hyperkeratosis on the palms and soles. c. Widespread maculae or streaky hyperkeratosis on the palms and the soles or
several large varicose hyperkeratosis either on the palms and soles or on the dorsum of the hands and the soles, with fissuring, ulceration and bleeding in some cases.
Common Dermatological Manifestations
a. Pigmentary changes in the skin or mucous membrane i.e. hyper pigmentation (melanosis), leukmelanosis.
b. Hyperkeratinization, i.e. hyperkeratosis. Common Non-Dermatological Manifestations
a. Weakness and asthenia. b. Conjunctival illness. c. Respiratory illness, i.e. chronic cough, bronchitis and asthma. d. Peripheral neuropathy, i.e. Tingling, Numbness, Burning and pain.
60
Probable Complications a. Non-pitting oedema. b. Peripheral vascular disease (gangrene). c. Chronic ulcers. d. Bowen’s Disease (pre-malignant skin condition). e. Squamous cell carcinoma (SCC). f. Basal cell carcinoma(bcc). g. Hepatopathy. h. Nephropathy. i. Cancer of internal organs, i.e. Urinary bladder, lung and prostate. j. Adverse pregnancy outcomes (spontaneous abortion, stillbirth and miscarriages. k. Diabetes mellitus. l. Hypertension.
3. EVIDENCE OF EXPOSURE
a. History of exposure: History of consumption of arsenic-contaminated water (>
50 ppb) for period of exceeding six months. b. Evidence of high levels of arsenic by biological sample analysis (BSA).
1) Nail: arsenic level > 1.00 mg/kg. 2) Urine: (in absence of intake of seafood) arsenic level > 50 ug As/L is
indicative of continuing exposure. 3) Hair: arsenic level > 1.0 mg/ kg.
4. OPERATIONAL DEFINITIONS Pigmentary Changes a. Hyperpigmentation (melanosis)
1) Early – Diffuse or spotted blackening of palm, trunk and or mucous membrane (gum, tongue and bucal mucosa).
2) Late – Extensive, diffuse or spotted dense pigmentation affecting the trunk and other parts of the body.
b. Leukomelanosis
Depigmentation in hyperpigmented areas characterized by whitish or pallor macules/patches commonly referred to as raindrop pigmentation.
Hyperkeratinization of skin (hyperkeratosis) Hyperkeratinization of skin or hyperkeratosis refers to abnormally rough and dry thickening of palms and soles, which is mostly bilateral. The symptoms can be categorized as under:
61
a. Mild – Just palpable thickening of palms and soles giving a gritty sensation on palpation, in absence of any obvious visible change.
b. Moderate – Palpable and visible multiple spotted or diffuse thickening of palms and soles.
c. Severe – Multiple wart or plaque like elevation (discrete/confluent) on palms and soles, and in addition may be present on other parts of the body.
5. MISCELLANEOUS RECOMMENDATIONS – CASE DIAGNOSIS
a. Establishing and maintaining an efficient and effective referral chain for clinical arsenicosis case diagnosis.
b. Detection and reporting of cases should be implemented – in the light of chain of evacuation of causality.
c. Health workers need to be trained as soon as possible on case detections.
d. Establishment of high quality laboratories for epidemiological and diagnostic investigation.
e. A multi-disciplinary, autonomous, International Centre for arsenic mitigation be established in Pakistan to act as a centre of excellence for arsenic related research.
f. Issues related to arsenicosis, both clinical and public health related, should be incorporated into the curriculum of medical institutions.
g. Establishment of multi-disciplinary National Task Force for the identification, formulation of strategies and monitoring to effectively combat the menace of arsenic contamination.
62
II. Flow Diagram – Diagnosis or Asenicosis
Symptoms – Affected Persons Points For Consideration (Any single point-presence) * Margin Elevated (hyper pigmentation) inhyperpigmentat * Presence of inflammatory ring ? On unexposed parts * Scaling over lesion. * Appearance on the face only ? Of the body(Trunk) * Hyperpigmentation along the palm creases * Hyperkerstosis – on trunk or temple ? Or palms * Patients in the Fmaily Spotted Or bilateral * Hyperkeratosis- on the repeated truma ? SOCIAL HISTORY-PATIENT Referred for Treatment (Normal) Urgent water check for As Clinical Evaluation Specialist Consultation (If As contamination + ve) Complications ----- Yes BHU management
Complications------No
Modified flow diagram from Bangladesh model
• Pigmentary changes On unexposed parts of the Body (trunk) or palms (diffuse or spotted) • Bilateral Palmoplantar Hyperkeratosis
• History of exposure to arsenic • Someone in the family or in neighborhood suffering with similar disease symptoms • Physical & chemical quality of drinking water sources. • Living & geo-economical condition of the patients
Yes Yes Poor quality Adverse/poor
• By birth symptoms? • Time period - since appeared ? • Symptoms – due to reaction of any drug? • Margin Elevated (in hyper pigmentation) • Presence of inflammatory ring ? • Scaling over lesion ? • Symptoms present on face only? • Hyper pigmentation along palm creases ? • Hyperkeratosis – on trunk or temple? • Hyperkeratosis only on the spots subjected to
repeated trauma
No
63
III. Arsenicosis Case Management
SYMPTOMS/MANIFESTATIONS
ACTIONS/MANAGEMENT
• Pigmentary appearance (early or late appearance) • Abnormal keratinization (Mild or moderate ) • Conjunctivitis/Conjunctival Congestion. • Respiratory illness
• Seize & stop intake arsenic contaminated water and switch to arsenic free safe water. • Dietary supplementation. • application of Keratolytic ( 5 – 20 % Urea Salicylicacid ointment ) for moderate keratosis. • Symptomatic treatment. • Follow-up and counseling with experts.
• Pigmentary changes including leukomelanosis • Severe kyperkeratinization of skin. • Non-pitting oedema of legs. • Peripheral neuropathy. • Nephropathy (early). • Hepatopathy (early)
• Stop intake of arsenic contaminated water and
switch to arsenic free safe water. • Dietary supplementation. • Application of Keratolytic (5–20% Urea salicylic
acid ointment). • Cryosurgery/operative removal of hyperkeratosis
lesion. • Symptomatic treatment. • Follow-up and continuous counseling with
experts/specialist.
In addition to one or more of the above: • Peripheral vascular disease including
• Stop intake of arsenic contaminated water and take
arsenic free safe water. • Complication – specific management. • Operative treatment. • Chemotherapy & or radiotherapy for cancers. • Follow-up and continuous consultation with
specialist/experts.
64
Annexure-I
Types of Adsorbents and their Arsenic Removal Efficiencies % Removal Sr.
![Page 1: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/1.jpg)
![Page 2: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/2.jpg)
![Page 3: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/3.jpg)
![Page 4: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/4.jpg)
![Page 5: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/5.jpg)
![Page 6: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/6.jpg)
![Page 7: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/7.jpg)
![Page 8: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/8.jpg)
![Page 9: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/9.jpg)
![Page 10: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/10.jpg)
![Page 11: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/11.jpg)
![Page 12: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/12.jpg)
![Page 13: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/13.jpg)
![Page 14: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/14.jpg)
![Page 15: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/15.jpg)
![Page 16: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/16.jpg)
![Page 17: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/17.jpg)
![Page 18: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/18.jpg)
![Page 19: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/19.jpg)
![Page 20: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/20.jpg)
![Page 21: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/21.jpg)
![Page 22: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/22.jpg)
![Page 23: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/23.jpg)
![Page 24: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/24.jpg)
![Page 25: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/25.jpg)
![Page 26: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/26.jpg)
![Page 27: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/27.jpg)
![Page 28: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/28.jpg)
![Page 29: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/29.jpg)
![Page 30: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/30.jpg)
![Page 31: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/31.jpg)
![Page 32: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/32.jpg)
![Page 33: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/33.jpg)
![Page 34: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/34.jpg)
![Page 35: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/35.jpg)
![Page 36: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/36.jpg)
![Page 37: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/37.jpg)
![Page 38: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/38.jpg)
![Page 39: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/39.jpg)
![Page 40: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/40.jpg)
![Page 41: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/41.jpg)
![Page 42: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/42.jpg)
![Page 43: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/43.jpg)
![Page 44: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/44.jpg)
![Page 45: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/45.jpg)
![Page 46: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/46.jpg)
![Page 47: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/47.jpg)
![Page 48: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/48.jpg)
![Page 49: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/49.jpg)
![Page 50: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/50.jpg)
![Page 51: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/51.jpg)
![Page 52: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/52.jpg)
![Page 53: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/53.jpg)
![Page 54: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/54.jpg)
![Page 55: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/55.jpg)
![Page 56: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/56.jpg)
![Page 57: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/57.jpg)
![Page 58: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/58.jpg)
![Page 59: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/59.jpg)
![Page 60: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/60.jpg)
![Page 61: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/61.jpg)
![Page 62: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/62.jpg)
![Page 63: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/63.jpg)
![Page 64: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/64.jpg)
![Page 65: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/65.jpg)
![Page 66: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/66.jpg)
![Page 67: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/67.jpg)
![Page 68: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/68.jpg)
![Page 69: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/69.jpg)
![Page 70: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/70.jpg)
![Page 71: 3.Pakistan Arsenic Mitigation Plan[1]](https://reader033.documents.pub/reader033/viewer/2022052504/55261c035503468e6e8b4b4b/html5/thumbnails/71.jpg)
