It is a day like any other at Mahavir Cancer Sansthan.

The driveway is lined with people who have travelled a long way to get to this charitable hospital in Patna. Families sit huddled, holding their bags close. The lobby is even more crowded, rather like the ticket buying hall of a train station.

The hospital gets between 60 and 100 patients every day – a substantial number for a 400-bed hospital. Ashok Ghosh, who heads research at the hospital, said that the load is such that “surgery has a two-month waiting list even though the disease might become inoperable by then”.

On the morning this reporter met him, Ghosh made a wry comment about the rush, asking: “When you entered this hospital, did this look like a cancer hospital or a general hospital?”

One reason this hospital is receiving so many patients is the dismal state of public healthcare in Bihar. Government hospitals are understaffed and poorly equipped. While the state has seen a jump in the number of private hospitals, most of them are too expensive for middle income and poor families in the state. Most of them, Ghosh said, end up coming to Mahavir Cancer Sansthan.

But lack of affordable care is not the only reason. Tata Memorial Hospital in Mumbai, one of the best cancer treatment facilities in India, gets about 25,000 patients every year from around the country. In contrast, Mahavir Cancer Sansthan gets nearly as many at about 22,000 patients last year despite drawing patients from just Bihar, Uttar Pradesh and Nepal. Many of these patients suffer from cancers of the gall bladder or liver, both which are associated with arsenic toxicity.

Outside the Mahavir Cancer Sansthan.
Outside the Mahavir Cancer Sansthan.

Bihar’s arsenic problem

Bihar’s heavy cancer burden is largely due to high levels of arsenic, a known carcinogen, in its groundwater. Pollution standards in India peg arsenic concentrations above 50 parts per billion as harmful. This is higher than the permissible limit of 10 parts per billion of arsenic in drinking water set by the United States.

Over the last 15 years, field studies in Bihar have thrown up arsenic concentrations that are far higher – up to 3,880 parts per billion.

Sunil Kumar, a professor at the agriculture university in Bihar’s Sabour block, studied arsenic levels in 16 blocks of Bhagalpur district. He found safe levels in just three blocks. Levels in other blocks were 3,880 parts per billion in Kahalgam, 3,610 parts per billion in Pirpainti and 3,500 parts per billion in Nathnagar.

Nupur Bose, a professor at Patna’s AN College, found arsenic levels as high as 1,861 parts per billion and 500 parts per billion in Bhojpur and Vaishali districts.

Arsenic has entered Bihar’s drinking water from the Himalayas, washed down in the form of arsenopyrite, a conjugate of arsenic and iron, till it settled in riverbeds along the Gangetic plain as silt. When the rivers changed course, human settlements sprung up on the floodplains. People in such settlements in Bihar, Uttar Pradesh,West Bengal and Bangladesh, used river water for drinking and irrigation.

In 1970s, concerned over the high levels of bacterial contamination in river water that was leading to the spread of diseases like diarrhoea, international health organisations advocated a shift to the use of groundwater pumped by borewells. The recommendation had unforeseen and expensive consequences. Arsenopyrite, found between 60 feet and 200 feet underground, is stable as long as it is insulated from air. But, as Ghosh explained, as groundwater levels fell below 60 feet, this underground arsenopyrite came in contact with air and split into the ionic forms of arsenic and iron both which easily enter water and are taken up by cattle and locally-grown crops and ultimately ingested by humans.

The link to disease

The implications of prolonged exposure to high concentrations of arsenic have been predictably dire.

Tilak Rai Ka Hatta is a village in Bihar’s Buxar district and home to 5,348 people. According to the 2011 census, this village’s groundwater has high arsenic levels. A study by Arun Kumar, who works with Ghosh at Mahavir Cancer Sansthan, and led the study, found most of the village had very high exposure to arsenic – no less than 80% of the village chapakals or handpumps had arsenic-contaminated groundwater. Of the chapakals surveyed, 75% had arsenic levels above 100 parts per billion. Even handpumps in the village’s primary and middle schools had arsenic concentrations of 100 parts per billion. The children studying here had hard patches called hyperkeratosis on their palms and soles, a condition caused by arsenic

The researchers found that 28% of the families surveyed in the village suffered from skin-related problems. As many as 86% suffered from gastritis, 57% from liver-related problems, and 64% reported a loss of appetite. The team documented cases of male and female infertility, as well as six cancer cases – four people had died while two were still suffering.

Ranjit Kumar, a member of Ghosh’s research team who worked on the Tilak Rai Ka Hatta study, said some families in the village had very high mortality levels. One such family is Ganesh Rai’s. When Kumar had met him, Rai was suffering from cancer. “Seven members of his family had died before crossing 55 years,” said Kumar. “One at the age of 30.”

Going by the descriptions, he said that their ailments might have been linked to cancer.

Arsenic at concentrations even below 50 parts per billion are very harmful. Arsenic levels between 10 parts per billion and 40 parts per billion have been linked to ailments like heart disease, impaired lung function and skin lesions like melanosis and keratosis – known precursors to skin cancer. In 2001, the US’ National Resource Council declared that one in every 300 people exposed to 10 parts per billion of arsenic a lifetime would develop some variety of cancer. This itself is considered a high rate of risk of developing the disease.

A lack of consensus

Despite researchers flagging high arsenic levels in Bihar’s Bhojpur district as far back as 2002, there is still little consensus on the scale of the problem. Are arsenic levels high in a few, isolated villages? Or are they high across the state?

A paper published in Environmental & Analytical Toxicology estimates that over five million people in the state are drinking water with arsenic levels greater than 10 parts per billion.

But Bihar’s Public Health Engineering Department, which is tasked with supplying clean water to people, have a more conservative estimate. It pegs the number of affected districts at 13, affected blocks at 50 and affected habitations at 1,590.

These numbers are challenged by researchers. While government data showed only four blocks in Bhagalpur have high arsenic levels, Kumar’s study found high levels of arsenic in 13 of Bhagalpur’s 16 blocks. AN College’s Nupur Bose, who has been working on arsenic contamination from 2004, said arsenic levels are high in as many as 36 of Bihar’s 38 districts.

Given these contestations, it is difficult to estimate the number of people at risk.

The state’s response

As striking as the lack of consensus over the scale of the problem is the state’s response to the villages where high arsenic levels were found.

About ten years ago, high arsenic levels were detected in Shahpur, a village near Bhagalpur. Remedial actions were carried out only in 2011, when a company from Gurgaon installed an arsenic filtration unit in the village. These units combat arsenic contamination by running groundwater through multiple filters.

Another option would have been to create alternative sources of clean water by supplying river water, turning to open wells, or drilling deeper into the earth below the arsenic belt.

According to Tripurari Prasad Singh, who belongs to Shahpur and was appointed as the caretaker of the filtration unit, the Gurgaon company ran the machines for four years but never once visited the unit it was installed. A second company that took over the contract, ran the unit for another 18 months but did not visit the site either. A third company was running the unit in March ths year. In all this time, he said, the filters have not been changed even once.

Down the street from this filtration unit was a second unit where the filters had just been changed. According to Devkaran, a young man sitting on a cot just outside the unit, before the filter change, the water was yellow. Lacking any option, people in the area had been drinking the water anyway.

Water filtration unit at Shahpur.
Water filtration unit at Shahpur.

It is a common refrain in Bhagalpur that the state government has set up water filtration units but their filters have not been changed. Over time, the filters get so saturated they cannot soak up any more arsenic. In her studies, Bose found units where the processed water actually had higher arsenic levels than the raw water. “The filter itself was leaching arsenic,” she said.

A report by researchers from the Delft Institute of Technology, Netherlands, corroborates Kumar’s and Bose’s findings. Studying arsenic mitigation in Bihar, they found some of the filters were yielding arsenic levels above the “legal limit”. They suggested this might be because filters had not been replaced in time.

An official at the public health engineering department in Bhagalpur concurred. “The filters have to be changed every eight-nine months. But they haven’t been [changed],” he said. He traced the problem to the fact that Bihar government subcontracts the installation and maintenance of the filters. Over the last five-six years, the government has centralised the awarding of these tenders – giving progressively larger tenders for installing and running these units. The official, who spoke on the condition of anonymity, said the installing company has to run these for the first 18 months. After that, a second tender for operations and maintenance is awarded for three years.

The official cited the example of two Gurgaon-based companies that won these tenders in 2009-’10, one for 400 units and the other for 300 units. Both companies failed to meet their targets, he said. “The first set up just 80 or 90 filters, while the second set up about 50.”

Penalising such companies is not easy, the official added. Local companies can be hauled up by the district office or by local protesters. But when the contracts are awarded at the state capital level all his office can do is write letters to the head office in Patna stating that these companies are not working.

“When we try and suspend a company for not doing its work, it goes to the courts,” he said. The companies often get a stay order. “Any hope of transferring the task to another company gets delayed.”

In the meantime, villagers continue drinking water from units with old filters, which is no different from drinking raw water. In more than 550 villages where the two companies failed to set up filtration units, people drink raw water anyway.

When Ghosh and his colleagues plotted where most of their patients come from, the map coincided with the regions with high arsenic numbers. All this helps explain the crowds at Mahavir Cancer Sansthan.

Source: Mahavir Cancer Sansthan
Source: Mahavir Cancer Sansthan
Source: Mahavir Cancer Sansthan
Source: Mahavir Cancer Sansthan

Scroll.in’s attempts to understand why bidding for these tenders had been centralised were unsuccessful. SN Mishra, executive engineer for monitoring at the public health engineering department did not respond to Scroll.in’s phone calls seeking a meeting. Emails to KNP Verma, the minister in charge of the department, and Anshuli Arya, the department’s principal secretary, did not get a response.

All photos by M Rajshekhar.

In the last two years, Scroll.in’s Ear To The Ground series has looked at, among other things, governance in Mizoram, Manipur, Odisha, Punjab and Tamil Nadu. Our reporting in Bihar began in October 2016. As we moved around the state, arsenic contamination appeared to encapsulate a key puzzle about Bihar: the state government’s response to crucial challenges facing its people seemed to be very weak. The next set of articles in this series will explore this big question.