THE “POISONED” BODY: AN ANTHROPOLOGICAL STUDY OF ARSENICOSIS IN RURAL BANGLADESH MD SAIFUL ISLAM (MPhil, Anthropology, Chinese University of Hong Kong) A THESIS SUBMITTED FOR THE DEGREE OF DOCTOR OF PHILOSOPHY DEPARTMENT OF SOCIOLOGY NATIONAL UNIVERSITY OF SINGAPORE 2010 ACKNOWLEDGEMENTS My years of PhD study at the National University of Singapore (NUS) and fieldwork in Bangladesh that have culminated in this thesis have left me indebted to many individuals and organizations. First and foremost, I wish to extend my sincere thank to the villagers of Rupnogor, who accepted and accommodated me, and willingly shared their insights and experiences of their everyday lives. Without them, this study would not have been possible. Although I hesitate to name any individuals for fear of overlooking others, I must convey my special thanks to Mr. Altaf Hossain and his family members, who considered me their “brother” and introduced me to the community in the early days of my fieldwork. My fieldwork in this village may not have been possible without their help. Thanks are also due to Mr. Abdur Rouf, the headmaster of the village high school, who shared invaluable information with me. I would also like to convey my special gratitude to the arsenicosis patients, their family members, the village doctor, alternative healers and many other villagers who graciously sacrificed their time to share information with me. This research would only be successful if it is able to be of some help to these individuals who suffer from deadly arsenicosis, for which there is no cure. I express my special thanks to many officials in many organizations who provided invaluable information about arsenicosis and various development initiatives. I am thankful to the officials of Bangladesh Arsenic Mitigation Water Supply Project (BAMWSP), the Department of Public Health Engineering (DPHE), the World BankDhaka office, the UNICEF-Dhaka office, and GlaxoSmithKline (GSK). At the National University of Singapore (NUS), I am especially grateful to my supervisor, Dr. Vineeta Sinha, who motivated me to think critically and to study arsenicosis anthropologically. This thesis would not have formed its present shape without her constant assistance, reassurance, careful reading of the manuscript and invaluable comments on it. I would like to honour the memory of Dr. Ananda Rajah, who was my first supervisor but passed away precipitously and unexpectedly, leaving the whole university in mourning. As a person and as a learned anthropologist, he can never be replaced. I would also like to thank Dr. Rachel Safman, another member of my doctoral committee, who initially contributed in developing my proposal but left the department for a further career opportunity. I am fortunate to have come across the excellent teachers in this department. I extend my sincere thanks to all of them. I thank NUS for awarding me a Research Scholarship, a President‟s Graduate Fellowship and the Graduate Research Support Scheme (GRSS), all of which enabled me to live in Singapore, conduct research in Bangladesh, and pursue my PhD study. I am also grateful to my friends in NUS who have sustained me throughout my PhD study. I am happy to have friends like Seuty Sabur, Siddiqur Rahman, Sarada Prasanna Das, Sojin Shin, Masud Parvez Rana, Kelvin Low, Reiko Yamagishi, Yang Chengsheng, Cheong Kah Meng, Chen Baogang, Thomas Barker, Yang Wei, and many others. Special thanks go out to Sarbeswar Sahoo, Lou Antolihao and Sim Hee Juat for their time, intellectual debate, “friendly hostility”, lunch, dinner, and what not. ii In Bangladesh, I owe special thanks to the University of Dhaka for granting me study leave, which allowed me to go abroad to pursue my PhD. I am greatly indebted to Prof. Taiabur Rahman, who persistently encouraged me to pursue my PhD abroad. I am also thankful to Prof. Mahbub Ullah, Prof. Atiur Rahman, and Prof. Niaz Ahmed Khan at the Department of Development Studies in Dhaka University; Prof. Harun-or-Rashid, Pro-Vice Chancellor of Dhaka University; Prof. Zahidul Islam, Department of Anthropology in Dhaka University; and Prof. A. H. M. Zehadul Karim, founder chairman of Anthropology in Rajshahi University, for their inspiration and motivation to pursue my higher studies abroad. My family has always been a source of inspiration to me. I thank my parents, who not only taught me to dream, but also provided everything they could afford to make my dreams possible to achieve. Despite weathering a financial crisis, they continued to support my tertiary education, and it is because of them that I am where I am today. My wife, Nila, has experienced a lot of difficulty with our two young daughters, Adrita and Anisha. During the latter part of my PhD study, I was unable to have my family with me in Singapore. Nila stayed back in Bangladesh, took care of our daughters and freed me to continue my studies. No words can express the level of her sacrifice, patience and understanding. This separation also affected my young children, who missed their “baba” for a long time. It is because of their sacrifices that I have been able to complete my thesis. It is with deep affection that I dedicate this thesis to Nila, Adrita and Anisha. iii TABLE OF CONTENTS Acknowledgements………………………………………………………………………………ii Table of Contents……………………………………………………………………………… .iv Abstract………………………………………………………………………………………….vii List of Tables………………………………………………………………………………… .viii List of Figures……………………………………………………………………………… ix List of Maps………………………………………………………………………………… x List of Pictures………………………………………………………………………………… .xi List of Abbreviations………………………………………………………………………… xii 1. INTRODUCTION……………………………………………………………………………1 1.1 1.2 1.3 1.4 The Research Problem The “Tubewell Revolution” and a “Water Miracle” Magnitude of Arsenic Contamination in Bangladesh Research Objectives 1.4.1 Popular Perceptions of Arsenicosis 1.4.2 Health-seeking Behaviour of Arsenicosis Patients 1.4.3 Participation in Mitigation Strategies 1.5 Challenges of an Ethnographic Approach 1.6 Dissertation Outline 2. THEORETICAL AND CONCEPTUAL FRAMEWORKS…………………………… 20 2.1 2.2 2.3 2.4 Introduction Conceptualizing Arsenicosis through Social Constructionist Approaches Critical Medical Anthropology: Situating Arsenicosis into the Political Economy Post-structuralist Development Discourse: Conceptualizing Development Projects as “Failure” 2.5 Medical Pluralism: A Relevant Concept? 2.6 Health-seeking Behaviour in a Medically Plural Setting 2.7 Conclusion 3. FIELDWORK AND RESEARCH METHODOLOGY… .47 3.1 3.2 3.3 3.4 3.5 3.6 3.7 Introduction Constructing the Field-site Getting Access to the Field-site Collecting Ethnographic Data Sampling Frame and Methodology Categories of Informants Conclusion 4. EVOLUTION OF MEDICAL SYSTEMS IN BANGLADESH AND THE EMERGENCE OF ARSENIC CONTAMINATION…………………………………….70 4.1 Introduction 4.2 Evolution of Medical Systems through Ancient and Colonial Bengal 4.3 Bangladesh: The Post-Colonial Context iv 4.3.1 4.3.2 4.3.3 4.3.4 The State, Government and Politics People, Culture and Economy NGOs and Development Programs Health-Care Systems The Professional Sector The Para-professional Sector The Traditional Sector 4.4 Arsenic Contamination: Its Causes and Health Consequences 4.4.1 Causes of Arsenic Contamination Natural Causes Human-induced Causes 4.4.2 Arsenic Toxicity and Human Health 4.5 Conclusion 5. GHAA: THE SOCIAL CONSTRUCTION OF ARSENICOSIS……………………….107 5.1 Introduction 5.2 General Health and Illness Beliefs and Practices of Rural Bangladesh 5.2.1 Conceptualizing Health (sustho) and Illness (osusthotha) 5.2.2 Dietary Rules and the concepts of Hot (gorom) and Cold (thanda) 5.2.3 Time, Space and Perceptions of Health and Illness 5.2.4 Fate (kopal/ vagyo) 5.2.5 Bad Weather (kharap abhawa) 5.3 Ghaa: The Social Construction of Arsenicosis 5.3.1 Arsenicosis as ghaa 5.3.2 Strong Poison vs. Mild Poison 5.3.3 Inside, Outside and the Poisoned Body 5.3.4 Increase, Decrease and Recurrence 5.3.5 Fate and the Curse of Allah 5.4 Conclusion 6. HEALTH-SEEKING BEHAVIOUR IN DEALING WITH GHAA………………… .147 6.1 Introduction 6.2 Ghaa and Health-seeking Behaviour in the Medical Supermarket of Rural Bangladesh 6.2.1 Barir Chikitsa: The Home-treatment of ghaa 6.2.2 Hujur: The Religious Healers 6.2.3 The Village kobiraj: Belief as Medicine 6.2.4 Doctors without Degrees: The Village Doctor and Local oshuder dokan 6.2.5 The Village homipoti daktar 6.2.6 The Professional Biomedical Health Care Services 6.3 Conclusion 7. COMMUNITY PARTICIPATION IN ARSENIC MITIGATION STRATEGIES……………… 196 7.1 Introduction 7.2 The BAMWSP: Background and Objectives 7.2.1 Project Structure and Implementation Process 7.2.2 Project Outcomes v 7.2.3 The Reality behind the Rhetoric: An Ethnographic Analysis of the Project 7.3 The GSK Water Treatment Plant 7.3.1 Formation of the Association for Arsenic Mitigation (AAM) 7.3.2 Installing the Arsenic Treatment Plant 7.3.3 Distributing Water and Maintaining the System 7.3.4 The Emergence of Unnoyon and Conflict with AAM 7.4 Explaining the Failure of the Water Treatment Plant 7.4.1 Different Perceptions and “The Growth of Ignorance” 7.4.2 The Politics of Participation 7.4.3 Conflict between AAM and Unnoyon 7.4.4 The Technological Burden 7.4.5 Water Quality: Fear, Suspicion and Taste 7.5 Conclusion 8. CONCLUSION: THE RELEVANCE OF CULTURE……………………………… 240 REFERENCES……………………………………………………………………………….252 vi ABSTRACT Recently, mass arsenic poisoning of groundwater has emerged as a public health crisis issue in Bangladesh. Apart from hundreds of deaths that have already been reported, 70 million people are estimated to be at high risk of developing deadly arsenicosis symptoms, including symmetric hyperkeratosis of the palms and soles, skin cancer, cancer of the kidneys and lungs, and diseases of the blood vessels. The severity and extent of arsenicosis have obliged the government of Bangladesh to declare it the “worst national disaster” the country has ever faced, and further to be deemed a “state of emergency.” To fight this pervasive public health disaster, the Bangladesh government has collaborated with the World Bank, WHO, UNICEF and various other international and national NGOs, which have channeled millions of dollars into implementing development projects to provide arsenic-free water to rural villagers. However, the majority of these projects have been rejected by the communities in which they have been instated and have thereby “failed”. In this context, this thesis explores two research problems: firstly, why arsenicosis patients, despite having fairly easy access to biomedicine, utilize alternative healing services, and secondly, why individuals who are suffering from arsenicosis reject options for arsenic-free water that could save them from this disease? To answer these questions, three areas have been identified for examination: (1) perceptions of arsenicosis by different social actors, (2) health-seeking behaviour of arsenicosis patients, and (3) community participation in arsenic mitigation strategies. Drawing upon ethnographic research conducted over a year in rural Southwestern Bangladesh, I first examine how arsenicosis is conceptualized and understood by different social actors, such as biomedical doctors, development planners and lay villagers. I articulate how biomedical professionals and development experts explain arsenicosis and then focus on how individuals, who are affected by arsenic poisoning, understand, experience and respond to this disease. By deconstructing the labels, vocabularies, etiologies and symptoms that individuals use to explain this disease, this thesis highlights how the biomedical reality of arsenicosis has been vernacularized as ghaa in practice. Taking this demonstration a step further, I analyze how such social construction of ghaa shapes health-seeking behaviour of subjects and their participation in mitigation strategies. This allows me to address these two questions through primary, ethnographic data. The ways in which biomedical and development professionals understand arsenicosis and even formulate solutions not make cultural sense on the ground. Individuals affected by arsenicosis use a very different cultural logic and worldview to explain this disease. I therefore argue that their low participation in public health-care services and the failure of arsenic mitigation strategies are a result of a “mismatch” in understanding arsenicosis. This thesis thus suggests that local knowledge, socio-political and ecological factors are collectively crucial and should be reflected in development policy formulations. For any health and development intervention to be successful and sustainable, a bottom-up approach with more meaningful community involvement and ownership could be ensured. vii LIST OF TABLES Table 1: Demographic Characteristics of Bangladesh……………………………… 81 Table 2: Economic Aspects of Bangladesh………………………………………… .83 Table 3: Global Occurrence of Arsenic Contamination………………………………95 Table 4: Local Terms Used to Explain ghaa…………………………………………133 Table 5: Financing of BAMWSP…………………………………………………….201 Table 6: The World Banks‟ Evaluation of the Project……………………………….208 viii LIST OF FIGURES Figure 1: Public Health Care Organization in Bangladesh…………………………88 Figure 3: BAMWSP Project Structure ………………………………………… 204 ix LIST OF MAPS Map 1: Arsenic Contamination in Bangladesh……………………………………………….7 Map 2: My Study Locale in Southwestern Bangladesh…………………………………… 48 Map 3: Location of my Field-site……………………………………………………………51 Map 4: Ancient Bengal………………………………………………………………………71 Map 5: Bengal in Ancient India…………………………………………………………… 72 Map 6: Map of Bangladesh………………………………………………………… .78 Map 7: Global Presence of Arsenic Contamination…………………………………………95 x of Public Health (MPH) Thesis. 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Delhi: Oxford University Press. 277 [...]... out of every 100 individuals in Bangladesh will develop bladder or lung cancer, resulting in an epidemic of cancer, in the next 10 years (Meharg 2005: 17) 8 These staggering statistics reveal the extent of the crisis facing Bangladeshis in accessing safe drinking water This human tragedy goes beyond issues of public health and it is literally a matter of life and death for millions of ordinary Bangladeshis... dollars in providing arsenic-free water to rural villagers A majority of these projects, however, are rejected by the communities in which they are implemented, and have therefore “failed” These “failures”, the continuing large scale of the problem and the tragedy of arsenicosis in Bangladesh have inspired the focus of this research This thesis explores the question of why individuals who are suffering... detailed survey of groundwater be conducted in order to map out the spatial spread of arsenic contamination These successive international conferences and campaigns played a major role in drawing the attention of the government and international organizations to the problem of arsenic contamination in Bangladesh Although arsenic contamination was first detected in Bangladesh in 1993, no initiative was... manifestations of Arsenicosis are appearances of melanosis, keratosis, hyperkeratosis, cancer and gangrene at the extremities 2 how such a social construction of arsenicosis departs from biomedical and official explanations, and to consider the general implications of such a departure on the healthseeking behaviour of subjects and their participation in mitigation strategies This approach to the analysis of arsenicosis. .. involves an examination of the patterns and histories of domestic water-use in rural Bangladesh 1.2 THE “TUBEWELL REVOLUTION” AND A “WATER MIRACLE” About 97% of rural Bangladeshis depend on groundwater for consumption, irrigation and various other needs (Kinniburgh et al 2003) Although tubewells have been in use since the 1940s for the purpose of extracting groundwater, the rate of installation was... mode of understanding arsenicosis, although a highly valuable one I am aware that there are many features of arsenicosis that the ethnographic perspective does not allow me to capture, and it is important to recognize the many other ways of approaching and understanding arsenicosis For this reason, it is important to balance the ethnographic approach with insights from other theoretical perspectives and... solve the puzzle of why arsenic mitigation strategies fail It is hypothesized that these mitigation strategies fail because of differential and contradictory perceptions and understandings of arsenicosis by different social actors Before setting out the precise objectives of this study, it is helpful to explicate a general understanding of the magnitude of arsenic poisoning in Bangladesh This involves an. .. among the most seriously contaminated countries in the world The groundwater of 59 (out of a total of 64) districts in Bangladesh is tainted with high concentrations of arsenic (The World Bank 2007) Apart from thousands of deaths having already been reported, about 85 million people are estimated to be at risk of developing arsenicosis symptoms, including symmetric hyperkeratosis of the palms and soles,... Group The World Bank xii 1 THE RESEARCH PROBLEM In November 1998, the New York Times reported that a “young mother, Pinjira Begum found out that her own slow dying was nothing unusual, that tens of thousands of Bangladeshi villagers are suffering the same ghastly decay, their skin spotted like spoiled fruit and warts and sores covering their hands and feet” (Cited in Meharg 2005: 2; Cullen 2008: 354) Pinjira... survey the extent of the problem It was Dipankar Chakraborti, along with a team from DCH, who surveyed 294 tubewells in the Chapai Nawabgonj district of Northeastern Bangladesh and found that 29% of the water samples had a high concentration of arsenic (Meharg 2005: 16) The same team conducted another survey in the Jessore district of Southwestern Bangladesh and found that 90% of tubewells there contained . hyperkeratosis of the palms and soles, skin cancer, cancer of the kidneys and lungs, and diseases of the blood vessels. The severity and extent of arsenicosis have obliged the government of Bangladesh. distribution of arsenic contamination in Bangladesh] : Map 1: Arsenic Contamination in Bangladesh (Source: Smedley and Kinniburgh 2002) 8 In another study, the Bangladesh Rural Advancement. communities in which they are implemented, and have therefore “failed”. These “failures”, the continuing large scale of the problem and the tragedy of arsenicosis in Bangladesh have inspired the focus