1. Groundwater quality and Human health
Sunderrajan Krishnan
CAREWATER
INREM Foundation,
Anand, Gujarat

2. Contents
Introduction
Main groundwater-health problems in India
Biological
Fluoride
Salinity
Nitrate
Arsenic
Iron
Emerging problems
Experiences in Fluorosis mitigation and learnings
Some debates on RO
Some thoughts on policy issues

3. Introduction
• Water borne diseases are a massive burden on society
• The impact of water borne diseases is higher on the poor
who have poorer nutrition
• Incidences of some water borne diseases are
decreasing, whereas others are increasing
• Most of these diseases are preventable by consumption
of safe drinking water

4. Local picture of drinking water access and variable water quality
Groundwater
Drinking
Piped water
supply Cooking
Tank/Pond
Other uses
Sources Domestic Uses

5. availability
time
Pond
supply
Sources
Piped water
Groundwater
salinity
availability fluoride
availability
Drinking
coli form
coli form coli form

6. Transport processes within the aquifer
Fl
Human, Animal waste
TDS
Fl Fertilizers, Pesticides
TDS TDS
Groundwater flow

7. Different contamination problems

8. Biological contamination
• Child mortality in India is 57/1000
• 9.1% of 0-5 yr mortality due to Diarrhoel diseases
• Overall DALY from Diarrhoel > 22 million years
• Poor sanitation and flood conditions are the main causes
• Several low cost filters are being developed now; yet
propensity to spend among poor not so high

9. Nitrate contamination
• Standards are for 45 mg/l
• Studies support Methaemoglobinemia in infants
• Suspicions for being carcinogenic, respiratory problems,
Diabetes
• Low cost solutions for Nitrate removal do not exist

10. Salinity
• Ingress and inherent salinity in many parts of India
• But what are the health symptoms from salinity?
• Can kidney stones be attributed to salinity? Though lack
of proper hydration is linked to Kidney stones, hardness
by itself is not
• Though there is high incidence of Kidney stone in
coastal areas

11. Total costs due to Kidney stones
In salinity affected villages,
• Medical costs = Rs. 5790 per person per year
• Wage loss costs = Rs. 2690 per person per year
• Drinking water costs = Rs. 750 per household per year
Social costs due to Kidney stones form a significant part of income

12. Source: ICAR Studies

13. Arsenic
• Arsenic in eastern parts of country
• Arsenicosis exposure to 16 million people (7 million > 50
ppb exposure)
• New areas in Nepal Terai, Assam, Bihar
• Linked closely to occurrence of Iron

14. Source: Jadavpur university

15. Iron
• Safe limit of 1 mg/l
• No health based guideline suggested by WHO
• People report of gastro-enteritic problems, but not supported by
medical studies
• Iron overload, Hereditary Haemochromatosis, Liver Cirrhosis
• Taste, odour, skin, hair, pipes, cooking
• People resort to unsafe water due to taste of Iron
• Link with Arsenic

16. Fluoride contamination
• Hydro-Fluorosis causes by consumption of high Fluoride
in water
• Not just Dental and Skeletal Fluorosis, but variety of
problems with brain, liver, kidney, heart diseases
• Estimates vary from 10 to 65 million people exposed
• DALY of 38.5 per 1000 population (NEERI, 2007)

17. Source: CGWB

18. Food
(black tea, rock salt) Occupation
(Mines, glass etching)
Water Nutrition
(Ca, Mg,
Vitamins)
Crops Fluorosis
Metabolism
Social, economic, cultural impacts
(effect of medicines, wage loss, psychological setback)
Society

19. Fluorosis mitigation programmes
• More than 50% of Fluoride intake can be through food
grown locally
• Fluorosis is linked much with climatic and nutritive
factors
• Teaching of Fluorosis is not present in current Indian
medicine or engineering literature
• Fluorosis patients can incur high costs (wage + medicine
losses)

20. Medical and Wage loss costs
North Dausa Kolar North
Gujarat (in 2005) (in 2005) Karnataka
(in 2002) (in 2005)
per capita Rs. 861 Rs. 1489 Rs. 2807
annual Rs. 1724
medical cost
per capita Rs. 4593 Rs. 19741 Rs. 8719 Rs. 12857
annual
wage loss
afflicted 1.1 1.3 1.7 2.3
no/house
hold
cost/annual 26 % 6% 21 % 16 %
income

21. Fluorosis mitigation programmes …. Cont’d
• Most Fluorosis mitigation programmes have been water
supply programmes
• Mitigation and reversal of symptoms is very slow, so
patients lose much hope after few years and resign to
fate

22. Fluorosis mitigation programmes …. Cont’d
• Started mainly as De-fluoridation programmes
• Nalgonda filter (using Alum) in 1970s … NEERI
• Activated Alumina (AA) as an advancement
• Reverse Osmosis (RO) with proper membrane can
remove Fluoride ions
• New materials, … Resin, Chitin, Bio-polymer adsorbent,
etc.

23. Fluorosis mitigation programmes …. Cont’d
• Water treatment: AA and RO
• Roof top rain water harvesting
• Pipe water supply
• Recharge

24. Fluorosis mitigation programmes …. Cont’d
• Main options today are AA and RO
• AA
Minimum of 1mg/g adsorption. Requires regeneration every 4-5
months
New materials with 8-9 mg/g adsorption
Al-Fl complexes a health concern
Has wide industry application, so is low-cost and available
AA filters not available in market
No electricity required
Two main programs for AA are SWACH and Mytry

25. Fluorosis mitigation programmes …. Cont’d
• SWACH and Mytry
UNICEF and IITK tested the AA DDU filters and implemented in 2
locations
Awareness programmes, village regeneration centres
Mytry later transitioned into filter manufacturing company
Currently some maintenance of filters happens in Rajasthan, but not
widespread

26. Fluorosis mitigation programmes …. Cont’d
Health based mitigation measures
Studies say upto 80% bio-available Fluoride enters through food
(Reddy R, 2008, AP) and 60% through food (Chakma, 2007, MP).
Safe water can prevent Fluorosis, but can it mitigate?
Calcium, Magnesium, Absorbic acid (Vitamin C) are suggested till now
Successes have been achieved for few patients by Dr. AK Susheela,
Dr. T. Chakma, Dr. Sunil Gupta and Dr. Raja Reddy
But can these be achieved on a larger scale? Nutrition supplements
through Atta, … other food items ?

27. Fluorosis mitigation programmes …. Cont’d
Fluorosis mitigation: water and health perspectives
• Understanding of Fluoride mobility and distribution
• Fluorosis needs to be in medical and public health
curriculum
• Doctors should push patients towards need for safe
water
• Mitigation needs to be tried in mass trials and
standardized
• Options for safe water needs to be available: rain water
storage, low cost treatment and services etc.

28. Debates with RO
• Cost/litre
• Effluent disposal
• Does it really treat for required contaminants?
• Maintenance
• Is it safe for health?
• Is it really required?

29. Successfully operating RO plants in south Gujarat
Minimum Average Maximum-
Capacity 250 lph 560 lph 1000 lph
Storage 200 litres 2000 litres 6000 litres
Plant cost 1.25 lakhs 2.32 lakhs 5 lakhs
Cost/litre 0 Re 0.28 Re 0.6
Prod/day 300 litres 1200 litres 2500 litres
Buyers in 30 86 325
village
Reach 10% 42% 100%
Suppliers of plant are varied (ISO, non-ISO)
Reach within village shows wide variation,
Off-shoot water suppliers cover surrounding villages,
Non-users have very poor drinking water facilities
Variability in size, cost/litre, % of reach and production

30. Treatment aspects of RO water
• RO treats only according to the specific membrane capacity
• Pre and post treatment is required
• Although pure distilled water can be harmful for health,
NRC, 1983 reports no health based guideline for RO water
• Effluent for RO should be disposed properly, but currently
no official safety standards exist in India

31. Monitoring of water quality
• Network of govt agencies insufficient
• NRDWQM program is in progress
• Several tier of monitoring eg. Assam where field kits are
employed along with 5 PHED labs and IIT G over seeing
quality control
• New low cost digital instrumentation are being developed
eg. in IIT B

32. Issues with policy
• Who is responsible for groundwater quality and health
problems?
• Do we have enough understanding of mobilization
processes of contaminants?

33. Health department’s role
• A framework on water quality should come from a
concept of overall health
• All water quality problems of a place need to be
addressed eg. Assam (Iron + Fluoride + Arsenic filter)
• Health agencies need to accept their responsibility

34. In summary
• Better physical distribution needs to be known
• Bringing people to be concerned on water quality and
health is not an easy task
• New treatment solutions coming up; but comprehensive
local solutions to water treatment needs to be developed
• Doctors can play a key role in disseminating water
quality information