More than 10 million people residing in 13 districts of the state of Bihar are facing the acute problem of arsenic contamination in drinking water. The objective of this paper is to quantify arsenic in drinking water, and to understand the associated health problems, health costs and socio-economic issues in the region. In the study, a field test kit was used to test the arsenic concentration in drinking water collected from 276 households. It was revealed that 63% of the households' drinking water contained arsenic in the excess of 10 ppb, 19.6% had arsenic concentration between 100 and <300 ppb, and 5% of the water samples contained arsenic between 300 and 500 ppb. Also, incidences of illness were found to be more frequent among children and females than among males. Monthly household cost and monthly per capita costs for the affected households and for all the surveyed households were found to be US$ 33.8 and US$ 3.9, and US$ 11.6 and US$ 1.3, respectively. The excess concentration of arsenic in drinking water over prolonged periods is likely to cause primary, secondary and tertiary health effects, and is a serious cause of concern.

INTRODUCTION

People living in Bihar are facing the significant health challenge of arsenic in drinking water, which has been mainly encountered in groundwater sources and is geogenic in nature. Groundwater is the main source of drinking water in Bihar and it constitutes more than 90% of drinking water sources in rural areas. Other sources of drinking water include protected sanitary dug wells, ponds, and natural sources like rivers and lakes. Groundwater sources are considered safe for consumption, but over the last few decades, pollution has been identified as a root-level challenge. Pollution has been mainly attributed to rapid urbanization, increase in population, industrialization, and excess uncontrolled extraction of groundwater for agriculture, industry and domestic purposes.

Arsenic in drinking water has both short- and long-term effects on human health. The positive association between arsenic in drinking water and cancer has been established by many studies from across the globe. Consumption of high levels of arsenic in drinking water over prolonged periods has been associated with skin lesions (Ahsan et al. 2000, 2006; Chakraborti et al. 2003; Lindberg et al. 2008; Argos et al. 2011; Pierce et al. 2011), melanosis and hyperkeratosis (Guha Mazumdar 2003, 2008; Rahman et al. 2006), reproductive disorders (Chattopadhyay et al. 2002; Chakraborti et al. 2003; Hopenhayn et al. 2003a, 2003b; Milton et al. 2004), cardiovascular disease (Lee et al. 2002; Tseng et al. 2003; Ana et al. 2005; Chen et al. 2011, 2013; Wu et al. 2012), and diabetes (Tseng et al. 2000, 2002; Tseng 2004; Pan et al. 2013). Clinical manifestation of arsenic also includes different forms of cancer such as skin cancer (Tseng 1977; Guo et al. 1998; Col et al. 1999; Smith et al. 2000; Luster & Simeonova 2004; Rossman et al. 2004), bladder cancer (Morales et al. 2000; Steinmaus et al. 2003; Bates et al. 2004), lung cancer (Hopenhayn et al. 1998; Chen et al. 2004; Chiu et al. 2004; Wu et al. 2004; Xia & Liu 2004; Marshall et al. 2007; Heck et al. 2009), and other non-cancer forms (Guha Mazumdar 2003; Ng et al. 2003; Tseng et al. 2005; Ahmed et al. 2006; James et al. 2015). The dose–response relation between low arsenic concentrations in drinking water and arsenic-induced skin keratosis and hyperpigmentation is well-characterized (Haque et al. 2003). Kapaj et al. (2006) reviewed chronic arsenic poisoning and its effects on human health and suggested both carcinogenic and non-carcinogenic effects of chronic arsenic exposure. Rahman et al. (2006), in their seven-year study in West Bengal, found that arsenic-affected patients had severe skin lesion problems.

Access to safe water supply is the most important determinant of health and socio-economic development (Cvjetanovic 1986). The Seventh Millennium Development Goals (MDGs) of the United Nations include ‘ensure environmental sustainability’. One of the targets of the seventh MDG is ‘also to halve, by 2015, the proportion of the population without sustainable access to safe drinking water and basic sanitation’ (UN 2009, 2010). Arsenic has a significant effect on the socio-economic structure, which includes social, economic and health-related problems along with a highly negative impact on agricultural productivity and change in the food chain system (Thakur et al. 2013).

The socio-economic problems due to contaminated drinking water can be mainly categorized into four classes: human health problem, social problem, environmental problem and economic problem. Contaminated water leads to a decrease in agricultural productivity and soil fertility, and also causes the entry of pollutants into the food chain, which creates serious health problems (Brammer & Peter 2009). Arsenic-induced diseases have economic impacts such as medical cost and loss in wage due to illness (Khan 2007; Roy 2008; Khan & Haque 2011). The annual health cost in Bangladesh due to excess arsenic content in drinking water has been estimated as US$ 2.7 billion (Maddison et al. 2005) while the cost of illness for Bangladesh, including mitigation expense, has been estimated as US$ 51 per household a year (Khan & Haque 2010). Roy (2008) assessed the economic cost of arsenic-related health problems in 24 North Parganas of West Bengal, India and estimated the economic cost to society as a whole as US$ 4.5 million. Khan & Haque (2011) estimated that households in Bangladesh spend nearly US$ 18 per year to deal with arsenic-related health problems. A recent study by Khan et al. (2014) found that the mean cost of arsenic-induced illness in Bangladesh was US$ 24 per household per year. An earlier study, which was conducted in Bangladesh, found that the mean household willingness to pay for water supply in arsenic-affected areas for community and individual (domestic) connection were US$ 43 and US$ 79, respectively (Ahmad et al. 2005).

In the early 2000s in Bihar, arsenic was detected in the groundwater at levels above the World Health Organization (WHO) standards, i.e., 10 ppb (parts per billion). Previous research indicates that over 10 million people living in the northern Bihar Gangetic plains are consuming water containing arsenic greater than 10 ppb. Saha (2009) reported that the southern bank of the River Ganga was more arsenic-prone than the northern bank, and arsenic was affecting more than 40% of Bihar's population. Ghosh et al. (2007, 2012), in their study, indicated the mixing of arsenic in drinking water and found that only two districts were arsenic-affected in 2002; however, in 2011, 18 districts had more than 50 ppb arsenic in drinking water. This comprises more than 77 blocks from 15 districts covering more than 1,650 habitations across the state (MoWR 2010b). Around 30 million people living in Bihar and West Bengal, India are potentially at risk due to consuming arsenic-contaminated drinking water (Ravenscroft et al. 2009) while more than 100 million people are affected in India and Bangladesh if one considers the WHO guidelines of 10 ppb (Chakraborti et al. 2009, 2010, 2015; Hossain et al. 2013).

Given this background, our paper explores the linkage between the consumption of arsenic-contaminated water and the long-term health effects with socio-economic implications in highly affected communities from two blocks in the state of Bihar. The paper is organized in the following manner. Following the Introduction, the materials and methods used are described. Next, the findings and observations from the field study are presented. The final section comprises the discussion and conclusions.

STUDY AREA AND METHODOLOGY

Study area description

The state of Bihar consists of 38 districts. Each district is further divided into subdivisions and several blocks, and blocks are further divided into Gram Panchayats (GPs). Each GP comprises several villages. Out of the 38 districts, 15 have been reported with a concentration of arsenic in groundwater above the permissible limit. This includes 65 blocks and more than 890 habitations with more than 50 ppb of arsenic, noted in drinking water by the BIS (Bureau of Indian Standard).

Maner and Shahpur blocks were selected for the study area because both were among the worst arsenic-affected blocks in Bihar. From secondary sources of information, it is revealed that Maner and Shahpur blocks reported 1,861 and 1,630 ppb of arsenic in hand pump tube well water samples, respectively (MoWR 2010a). In the past, a survey conducted by the Public Health Engineering Department (PHED), Government of Bihar, reported that the highest contamination of arsenic in both public and private hand pump tube wells was found in these two blocks. The Maner block has 10 GPs and 36 villages with a total population of 2,66,457 (Census 2011), and Shahpur block contains 10 GPs and 86 villages with a total population of 2,12,170 (Census 2011). Districts containing more than 50 ppb of arsenic in drinking water are illustrated in Figure 1.
Figure 1

Arsenic-affected districts in Bihar. Source: Public Health Engineering Department, Government of Bihar.

Figure 1

Arsenic-affected districts in Bihar. Source: Public Health Engineering Department, Government of Bihar.

Sampling framework

Multistage sampling procedures were used for data collection. In the first stage, all the 15 districts of Bihar where arsenic concentration is reported to be more than 50 ppb were chosen. Fifty ppb of arsenic concentration in drinking water was taken as the standard benchmark as suggested by BIS for safe drinking water. It was not possible to conduct the survey for all the 15 districts. Therefore, in the second stage, the study further narrowed down to 11 blocks from four districts containing higher arsenic concentration. Finally, on the basis of higher arsenic concentration, two blocks, namely, Maner and Shahpur from Patna and Bhojpur districts were selected. In the third stage, two GPs, one each from the Maner and Shahpur blocks were randomly selected for the household surveys. In the final stage, 276 households (140 from Maner and 136 from Shahpur) were randomly selected. Systematic random sampling was used for the selection of actual households and 10% of households from both the GPs were surveyed.

Water sample collection

Arsenic field test kits were used for testing the contamination level of the household drinking water. Arsenic field test kits provided by the Prerana laboratories were used; Prerana is one of the largest manufacturers of water testing kits and is accredited by WHO and BIS. Water samples were collected from hand tube wells of 276 households. The water samples were collected during March–May 2013. The results of the water test were based on the colour of strips used. If there is no change in the colour it indicates 0 ppb, slight change in colour indicates 10 ppb, light yellow indicates 50 ppb, yellow indicates 100 ppb, light orange indicates 300 ppb and dark orange indicates 500 ppb. The average reaction time of the chemicals is between 12 and 18 minutes. The test used for iron was qualitative.

Survey

The present study was conducted to collect primary data through a questionnaire-based survey during March to May, 2013. The questionnaire was divided into four sections. The first section aimed at collating demographic information while the second section provided information on the income and expenditure details of the households. The third section was based on information related to the health cost and other medical expenditure. In this section, we collected cost of visits to doctors, diagnostic and medication cost, and cost of hospitalization. The fourth section was dedicated to various socio-economic issues. It was difficult to identify patients with arsenicosis without the aid of trained medical practitioners, and to obtain that was beyond the scope of this study. Therefore, the present study relied on the symptoms of primary, secondary and tertiary diseases induced due to arsenic in drinking water, as described by the WHO (2010), Khan (2007) and Khan & Haque (2011).

The study surveyed 276 households comprising 2,380 persons. Of the 2,380 people, 55% were male and 45% were female. Of households, 81.2% were Hindus and 18.8% were Muslims. In the survey, two types of family structure were observed: joint and nuclear family with 53.1% households being from nuclear family while 46.9 were from joint family. The majority of the surveyed members were unmarried (52.9%), followed by married respondents (44.2%) and widows or widowers (2.9%). The average age of the respondents was 25.8 ± 1.1 years. The average household size was 8.6 ± 0.71, while the mean age of the household head was around 53.9 ± 2 years. Demographics and a few other variables are presented in Table 1.

Table 1

Demographics and other variables

Variables Mean Standard error 
Household size (in numbers) 8.6 0.71 
Household head age (in years) 53.9 
Age (in years) 25.8 1.1 
Education (in years) 7.5 0.74 
Income from primary occupation (in US$) 306.9 42.1 
Income from secondary occupation (in US$) 86.3 13.5 
Income from other sources (in US$) 32.5 12.6 
Household income (in US$) 425.6 55.9 
Household expenditure (in US$) 212.8 26.4 
Household health expenditure (outdoor) in US$ 12.6 4.8 
Household health expenditure (hospitalization) in US$ 58.4 35.1 
Household health expenditure (in US$ per month) 33.8 17.4 
Arsenic water contamination (in ppb) 115.8 6.8 
Variables Mean Standard error 
Household size (in numbers) 8.6 0.71 
Household head age (in years) 53.9 
Age (in years) 25.8 1.1 
Education (in years) 7.5 0.74 
Income from primary occupation (in US$) 306.9 42.1 
Income from secondary occupation (in US$) 86.3 13.5 
Income from other sources (in US$) 32.5 12.6 
Household income (in US$) 425.6 55.9 
Household expenditure (in US$) 212.8 26.4 
Household health expenditure (outdoor) in US$ 12.6 4.8 
Household health expenditure (hospitalization) in US$ 58.4 35.1 
Household health expenditure (in US$ per month) 33.8 17.4 
Arsenic water contamination (in ppb) 115.8 6.8 

Source: Author's own calculation from field survey.

RESULTS

Arsenic concentration of water in hand pump tube well water samples

For understanding the magnitude of arsenic contamination, water samples from 276 hand pump tube wells were tested from the study area. It was found that 81.2% of households in the study area had poor quality drinking water (either arsenic or iron or both), while 73.9% of households had excess iron in their drinking water. Mean concentration of arsenic contamination in the study area was found to be higher than the prescribed standard limit of WHO and BIS of 10 ppb and 50 ppb, respectively. It appears from the result of water sample analysis that 36.9% of water samples contained arsenic at concentrations less than 10 ppb, 16.3% samples contained concentrations between 10 and <50 ppb, 22.1% samples contained arsenic in the range of 50 to <100 ppb, 19.6% samples contained between 100 and <300 ppb of the metalloid, and 5% of the water samples had arsenic concentration between 300 and 500 ppb for the entire study area. Figure 2 presents the analysis of arsenic in water samples from hand pump tube wells.
Figure 2

Arsenic levels in hand pump tube well water samples. Source: field survey.

Figure 2

Arsenic levels in hand pump tube well water samples. Source: field survey.

The water sample analysis of the Maner block revealed that the problem of arsenic contamination was more severe here than in the Shahpur block. It was found that 92.1% households in the Maner block had poor quality water (either arsenic or iron or both), and 87.1% households had more than the prescribed limit of 300 ppb iron in their drinking water. From the analysis of water samples of the Maner block, it was found that 25% of the water samples contained arsenic at concentrations below 10 ppb, 17.9% samples contained 10 to <50 ppb arsenic, 31.4% samples had arsenic in the range of 50 to <100 ppb, 19.3% contained arsenic between 100 and <300 ppb, and 6.4% of the water samples contained the metalloid in the range of 300–500 ppb. More details of water sample analysis are shown in Figure 2.

Shahpur was the first block where arsenic was reported in 2002. From the field survey, it was found that 69.9% of households in Shahpur had poor water quality (either arsenic or iron or both), while 60.3% households had an excess of iron. Water sample analysis from the Shahpur block revealed that 19.9% households contained arsenic in the range of 100 to <300 ppb while 3.7% samples had arsenic in the range of 300–500 ppb. The range of arsenic concentration was 0–500 ppb. (The field test kit can test up to 500 ppb of arsenic in drinking water. Concentration more than 500 ppb can be detected only by laboratory test.)

Health problems

The study conducted a primary survey of 276 households, collating the health information of 2,380 individuals from two blocks of Bihar, India. The surveyed population consisted of 1,310 males and 1,070 females. The present study categorized arsenic-induced health problems into three categories: primary, secondary and tertiary health effects, as per earlier studies. (Primary, secondary and tertiary stages of arsenic-induced health effects are caused due to excess concentration of arsenic in drinking water over a prolonged period. In the present study, primary stage health effects are black spots in the body, keratosis, redness of the conjunctiva, conjunctivitis, inflammation of the respiratory tract and gastroenteritis. Secondary stage health effects include white and black spots on the body, hyperkeratosis, non-pitting oedema, peripheral neuropathy, and liver and kidney disorders. Gangrene of the distal organs and cancer are tertiary stage health effects.) The primary, secondary and tertiary stage health effects were observed carefully with the help of a medical team. From the analysis it was found that most of the arsenicosis patients (55%) were at the primary stage, followed by secondary stage patients (43%); only 2% of the total identified patients were in the tertiary stage. Black spots in the body (44%), thickening and roughness of the palms and soles (23%) and nausea and vomiting, i.e., gastroenteritis (32%) were the main primary stage health effects in the study area. White and black spots in the body (29%), hyperkeratosis (20%), swelling of the feet (28%), liver and kidney disorders (19%) and peripheral neuropathy (4%) were the main secondary stage health issues in the surveyed area. Kidney and liver failure (50%) and cancer (50%) were the main tertiary health issues. The details of arsenic-induced health issues and primary, secondary and tertiary stage health effects are presented in Figure 3.
Figure 3

(a) Arsenic-induced health issues, (b): arsenic-induced primary health issues; (c) arsenic-induced secondary health issues; (d) arsenic-induced tertiary health issues. Source: field survey.

Figure 3

(a) Arsenic-induced health issues, (b): arsenic-induced primary health issues; (c) arsenic-induced secondary health issues; (d) arsenic-induced tertiary health issues. Source: field survey.

The incidence rate of arsenic-induced health effects was estimated and it was found that women and children were more prone to arsenic disease than men. The incidence rate of arsenic disease was found to be 103.2, 94.5 and 86.6 among women, children and men, respectively.

Economic problems and health costs

The health cost was estimated on the basis of the cost associated with all the households vis-à-vis the affected households. Out of the 276 households, at least one member from 71 households was suffering from a health problem(s) due to contaminated drinking water. The frequency of visits to the doctor in the previous 6 months was one to eight times. Of the affected households, 36.4% visited a doctor eight times in the last 6 months, followed by 27.3% of households who visited the doctor twice. The remaining households had paid a visit to the doctor once in the last 6 months.

It was difficult to ascertain accurately the money spent on diseases caused by water contamination and diseases of other origins. Precautions were taken in gathering information on health cost due to contaminated drinking water. Discussion with the specialist doctors treating arsenic patients in Kolkata was useful in understanding the health problems associated with arsenic in drinking water (see Table 1 for descriptive statistics on demographic and other variables).

The average outpatient cost of visiting the doctor, treatment costs and transport costs were estimated as US$ 2.8, US$ 19.4 and US$ 3.7, respectively. Total households' costs and per person households' costs for outpatients were US$ 4.3 and $ 0.5 per month, respectively. The total inpatient cost for 6 months was US$ 43.8 and monthly household cost and monthly per capita costs were US$ 7.3 and US$ 0.85. Total average health cost of the households for 6 months came to US$ 69.8. The monthly average cost of the households was US$ 11.6 and per person household cost was US$ 1.4. Table 2 provides the detailed information on health costs accrued by the arsenic-affected and surveyed households.

Table 2

Mean estimation of the households' health cost (in US$)

Surveyed household health cost
 
Affected household health cost
 
            
Outpatient (n = 276) Monthly household cost Monthly per capita cost Outpatient (n = 71) Monthly household cost Monthly per capita cost 
Doctor visit 0.46 0.05 Doctor visit 1.35 0.15 
Treatment (including diagnostic cost) 3.23 0.37 Treatment (including diagnostic cost) 9.41 1.09 
Transport cost 0.62 0.07 Transport cost 1.80 0.20 
Total outpatient cost (n = 276) 4.32 0.50 Total outpatient cost (n = 71) 12.57 1.45 
Inpatient (hospitalization cost) (n = 276)   Inpatient (hospitalization cost) (n = 34)   
Doctor visit 0.29 0.03 Doctor visit (n = 34) 3.07 0.35 
Treatment (including diagnostic cost) 6.22 0.72 Treatment (including diagnostic cost) (n = 34) 49.84 5.77 
Transport cost 0.78 0.09 Transport cost (n = 34) 6.28 0.72 
Total inpatient cost (n = 276) 7.30 0.84 Total inpatient cost (n = 34) 58.44 6.77 
Total health cost (n = 276) 11.62 1.34 Total health cost (n = 71) 33.82 3.92 
Surveyed household health cost
 
Affected household health cost
 
            
Outpatient (n = 276) Monthly household cost Monthly per capita cost Outpatient (n = 71) Monthly household cost Monthly per capita cost 
Doctor visit 0.46 0.05 Doctor visit 1.35 0.15 
Treatment (including diagnostic cost) 3.23 0.37 Treatment (including diagnostic cost) 9.41 1.09 
Transport cost 0.62 0.07 Transport cost 1.80 0.20 
Total outpatient cost (n = 276) 4.32 0.50 Total outpatient cost (n = 71) 12.57 1.45 
Inpatient (hospitalization cost) (n = 276)   Inpatient (hospitalization cost) (n = 34)   
Doctor visit 0.29 0.03 Doctor visit (n = 34) 3.07 0.35 
Treatment (including diagnostic cost) 6.22 0.72 Treatment (including diagnostic cost) (n = 34) 49.84 5.77 
Transport cost 0.78 0.09 Transport cost (n = 34) 6.28 0.72 
Total inpatient cost (n = 276) 7.30 0.84 Total inpatient cost (n = 34) 58.44 6.77 
Total health cost (n = 276) 11.62 1.34 Total health cost (n = 71) 33.82 3.92 

Source: Author's own calculation from field survey.

Monthly household costs for outpatient costs, inpatient costs and health costs were US$ 12.6, US$ 58.4, and US$ 33.8, respectively. Monthly per capita cost of the household for outpatient cost, inpatient cost and total costs were US$ 1.5, US$ 6.8 and US$ 3.9, respectively. Monthly household cost and monthly per capita transportation cost of outpatients for a household were US$ 1.8 and US$ 0.2, respectively, while for the inpatient these costs were US$ 6.3 and US$ 0.72, respectively. Treatment cost included costs of medicines and diagnostic costs.

DISCUSSION AND CONCLUSIONS

The groundwater contamination problem in India, particularly in Bihar, is increasing with every year. This is a serious concern as ingestion of water containing arsenic in the excess of 50 ppb over a long period results in various health effects. From our field survey it was found that 81.2% of households in the study area ingested poor quality water (either arsenic or iron or both), while 73.2% of households had excess iron in their drinking water; 63% households were consuming drinking water with greater than 10 ppb of arsenic. Around 5% of the households' water samples had arsenic concentration between 300 and 500 ppb. If the high concentration level of arsenic in drinking water continues for a few more years, arsenic gangrene and cancer are likely to be caused (Clarke 2001; Rahman et al. 2005; Chakraborti et al. 2010, 2015). The situation with arsenic pollution in the Maner block was more alarming than that in Shahpur. The mean arsenic concentration of the Maner and Shahpur blocks were found to be 131.8 ppb and 99.2 ppb, while the mean concentration of the entire study area was found to be 115.8 ppb.

Arsenic-induced health effects include primary, secondary and tertiary health issues. Primary health issues are black spots in the body, gastroenteritis, conjunctivitis and keratosis, while secondary health issues are white and black spots on the body, hyperkeratosis, swelling of the feet and legs, peripheral neuropathy and liver and kidney disorders. If untreated, it leads to skin cancer, cancer of the bladder, kidney and lung problems, which are tertiary health issues due to excess intake of arsenic in drinking water. From our survey, it was found that 55% of the identified patients were at the primary stage, 43% were at the secondary stage, while only 2% were in the tertiary stage. This may be because a relatively longer time period is required to reach the tertiary stage, as suggested by earlier studies (Guha Mazumdar et al. 1988; Smith et al. 2000; Clarke 2001; Rahman et al. 2005; Chakraborti et al. 2010, 2015). The incidence rate of arsenic health issues among women and children was found to be more than among men. Among women, children and men, the incidence rate of arsenic disease was found to be 103.2, 94.5 and 86.6, respectively. The findings of this study differ from the findings of earlier studies (Chakraborti et al. 2003; Rahman et al. 2005) where incidence rate among females was found to be lower than among men.

There is well documented evidence that arsenic exposure not only causes human health problems but is also associated with economic issues and a variety of other problems. Arsenic in drinking water escalates the social as well as economic costs of the community in general and of the affected households in particular. Skin lesions pose an important public health concern in Bangladesh and West Bengal (India), as advanced forms of keratosis, which are painful, and if untreated can lead to social ostracization (Haque et al. 2003). Since social isolation leads to loss in work days, its association with economic loss is undeniable.

Arsenic exposure has a negative economic effect on the people residing in the areas where the arsenic contamination hazard has been found. The average per month households' costs and per person households' costs for outpatients was found to be US$ 4.3 and $ 0.50, respectively. The monthly average cost of the households was US$ 11.6 and per person household cost was US$ 1.4. These results are in agreement with the earlier works of Roy (2008) in West Bengal, India and Khan (2007) from Bangladesh. The study also found that poor households incurred the largest number of sick days and a person suffering from arsenic-related disease worked fewer days than a healthy person, which is supported by the findings of Roy (2008) where a person suffering from arsenic-related disease worked only 2.73 hours per day compared to 8 hours work per day of a healthy person. The findings of the present study are also similar to that of Khan & Haque (2011), where they measured the private cost of arsenic exposure in Bangladesh. They found that households spent US$ 20.7 per year for arsenic-related ailments, which is nearly 0.73% of their income.

Children were found to be more prone and susceptible to arsenic poisoning, which makes the intra- and inter-generation more vulnerable. A few remediation plans have been initiated by the government, but due to poor implementation they have not achieved their purpose. Therefore, the government should act quickly to provide safe drinking water to the affected areas. Otherwise, the issue in Bihar will become more severe than that in Bangladesh with enormous impact on the current and future generations.

Importantly, some shortcomings of the study need to be discussed to encourage further research in the related area. This study only captured the medical expenditure of both outpatients and inpatients of arsenic-related diseases, but could not capture the cost of installing arsenic-safe deep hand pump tube wells and arsenic removal filters. The estimation of these costs will help to estimate the welfare gain estimates from arsenic removal. The other limitation of the study is the lack of focus on the temporal variability of arsenic contamination in the groundwater, which may affect the variability of health costs. In view of these limitations, the present study should be improved upon by future researchers.

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