1. The World Health Organization Drinking Water Guidelines for Toxic Inorganic Substances and Public Health in Bangladesh, India, and Myanmar Erika Mitchell, Ph.D. Donald Maynard, P.E. Thomas Bacquart, Ph.D. George Springston, M.S. Laurie Grigg, Ph.D. Seth Frisbie, Ph.D. Bibudhendra Sarkar, Ph.D. Hannah Dustin, B.S. Kelly Bradshaw, B.S. Jeffrey Defelice, B.S.

2. Many premature deaths were caused by drinking surface water.Many premature deaths were caused by drinking surface water. The life expectancy during the mid-1960s was only 46 years.The life expectancy during the mid-1960s was only 46 years. A History of Drinking Water in Bangladesh Rivers, ponds, and dug wells were the only practical source of drinking water for about 3,000 years until the 1970s.Rivers, ponds, and dug wells were the only practical source of drinking water for about 3,000 years until the 1970s. A massive cholera outbreak began in 1963.A massive cholera outbreak began in 1963. (Photograph by Dhaka Hospital)

3. Approximately 10,000,000 tubewells have been installed since 1971 to supply safe drinking water.Approximately 10,000,000 tubewells have been installed since 1971 to supply safe drinking water. Within 1 generation the population changed from drinking surface water to drinking groundwater.Within 1 generation the population changed from drinking surface water to drinking groundwater. By 2000, approximately 97% of Bangladeshis drank tubewell water.By 2000, approximately 97% of Bangladeshis drank tubewell water. (Photograph by Steven Brace, 1995) A History of Drinking Water in Bangladesh

4. The symptoms of chronic arsenic (As) poisoning from drinking water usually take 5 to 20 years to manifest.The symptoms of chronic arsenic (As) poisoning from drinking water usually take 5 to 20 years to manifest. Chronic As poisoning from drinking tubewell water was first diagnosed in 1993.Chronic As poisoning from drinking tubewell water was first diagnosed in 1993. Melanosis of the chest Keratosis of the palms (Photograph by Dhaka Community Hospital and Richard Wilson, 2002) Keratosis of the feet Blackfoot disease A History of Drinking Water in Bangladesh

5. The first national-scale map of As concentration in Bangladesh’s tubewell water was made in 1997.The first national-scale map of As concentration in Bangladesh’s tubewell water was made in 1997. Approximately 75,000,000 Bangladeshis are at risk of death from skin, bladder, liver, and lung cancers caused by chronic As poisoning.Approximately 75,000,000 Bangladeshis are at risk of death from skin, bladder, liver, and lung cancers caused by chronic As poisoning. The source of As is geological.The source of As is geological. Map of As concentration (mg/L). A History of Drinking Water in Bangladesh

6. a Assuming Bangladesh has 158,570,535 people (July 2011 est.) and 97% of its population drinks well water. Estimated number of Bangladeshis drinking water with metal concentrations above WHO guidelines. Metal Carcinogenic Potential WHO Guideline (µg/L) Percent of Bangladesh’s Area Exceeding WHO Guideline Number of Bangladeshis Drinking Unsafe Water a AsMnPbNiCr Known carcinogen Noncarcinogen Possible carcinogen Probable carcinogen Noncarcinogen1040010205049603 < 1 75,000,00092,000,0004,600,000 < 1,500,000 Tens of millions of Bangladeshis are drinking water that exceeds WHO health-based guidelines for As, manganese (Mn), lead (Pb), nickel (Ni), and chromium (Cr).Tens of millions of Bangladeshis are drinking water that exceeds WHO health-based guidelines for As, manganese (Mn), lead (Pb), nickel (Ni), and chromium (Cr). Boron (B), barium (Ba), molybdenum (Mo), and uranium (U) have also been found above WHO health-based guidelines in Bangladesh.Boron (B), barium (Ba), molybdenum (Mo), and uranium (U) have also been found above WHO health-based guidelines in Bangladesh.

7. The Discovery of Multiple Toxic Elements in West Bengal’s Drinking Water The deep well water from neighboring West Bengal, India has unsafe concentrations of As, B, fluoride (F - ), Mn, and possibly thorium (Th).The deep well water from neighboring West Bengal, India has unsafe concentrations of As, B, fluoride (F - ), Mn, and possibly thorium (Th).

8. The Discovery of Multiple Toxic Elements in Myanmar’s Drinking Water The deep well water from neighboring Myanmar has unsafe concentrations of As, F -, Mn, and U.The deep well water from neighboring Myanmar has unsafe concentrations of As, F -, Mn, and U. This rapid switch to deep well water is exposing hundreds of millions of people in south Asia to unsafe concentrations of metals.This rapid switch to deep well water is exposing hundreds of millions of people in south Asia to unsafe concentrations of metals. This has been called the largest mass poisoning in history.This has been called the largest mass poisoning in history.

9. In the most recent edition of Guidelines for Drinking-water Quality (2011), the World Health Organization (WHO) made its drinking-water guidelines less restrictive or did not establish guidelines for 9 chemicals that can cause adverse health effects and that are commonly found in drinking water.In the most recent edition of Guidelines for Drinking-water Quality (2011), the World Health Organization (WHO) made its drinking-water guidelines less restrictive or did not establish guidelines for 9 chemicals that can cause adverse health effects and that are commonly found in drinking water. The World Health Organization In contrast, the WHO did not make any guidelines more restrictive or establish any new guidelines for other chemicals from this family.In contrast, the WHO did not make any guidelines more restrictive or establish any new guidelines for other chemicals from this family.

10. WHO guidelines are not regulations, but may be used by governments or other stakeholders for setting local standards.WHO guidelines are not regulations, but may be used by governments or other stakeholders for setting local standards. Some countries, especially those with limited resources, use WHO guidelines as de facto standards.Some countries, especially those with limited resources, use WHO guidelines as de facto standards. The World Health Organization Therefore, these guidelines often directly affect the most disadvantaged populations.Therefore, these guidelines often directly affect the most disadvantaged populations.

11. The 400 µg/L drinking-water guideline for manganese (Mn) was discontinued by the WHO with the assertion that since “this health-based value is well above concentrations of manganese normally found in drinking-water, it is not considered necessary to derive a formal guideline value”.The 400 µg/L drinking-water guideline for manganese (Mn) was discontinued by the WHO with the assertion that since “this health-based value is well above concentrations of manganese normally found in drinking-water, it is not considered necessary to derive a formal guideline value”. The World Health Organization and Manganese (Image by Theodore Gray) However, over 50 countries have drinking-water supplies with manganese above 400 µg/L.However, over 50 countries have drinking-water supplies with manganese above 400 µg/L. In Bangladesh alone, over 90,000,000 people are drinking water with manganese above 400 µg/L.In Bangladesh alone, over 90,000,000 people are drinking water with manganese above 400 µg/L.

12. Similarly, the 70 µg/L drinking-water guideline for molybdenum (Mo) was discontinued by the WHO with the assertion that molybdenum “occurs in drinking-water at concentrations well below those of health concern”; therefore, “it is not considered necessary to set a formal guideline value”.Similarly, the 70 µg/L drinking-water guideline for molybdenum (Mo) was discontinued by the WHO with the assertion that molybdenum “occurs in drinking-water at concentrations well below those of health concern”; therefore, “it is not considered necessary to set a formal guideline value”. The World Health Organization and Molybdenum (Image by Theodore Gray) However, the WHO previously stated that in a “survey of 380 finished water samples from across the USA, 29.9% contained measurable concentrations of molybdenum, with a mean of 85.9 µg/litre and a range of 3-1024 µg/litre”.However, the WHO previously stated that in a “survey of 380 finished water samples from across the USA, 29.9% contained measurable concentrations of molybdenum, with a mean of 85.9 µg/litre and a range of 3-1024 µg/litre”.

13. The 200 µg/L drinking-water guideline for chronic or long-term exposure to nitrite (NO 2 - ) was suspended.The 200 µg/L drinking-water guideline for chronic or long-term exposure to nitrite (NO 2 - ) was suspended. The World Health Organization and Nitrite (Image by Theodore Gray) However, the WHO recommended that the “average exposures [of nitrite] over time should not exceed about [200 µg/L]”.However, the WHO recommended that the “average exposures [of nitrite] over time should not exceed about [200 µg/L]”. Given this recommendation, the decision to suspend the 200 µg/L guideline seems inconsistent.Given this recommendation, the decision to suspend the 200 µg/L guideline seems inconsistent.

14. The WHO stated that a 900 µg/L drinking-water guideline for aluminum (Al) “could be derived”; however, this guideline was not established.The WHO stated that a 900 µg/L drinking-water guideline for aluminum (Al) “could be derived”; however, this guideline was not established. The World Health Organization and Aluminum (Image by Theodore Gray) According to the WHO, aluminum is commonly found in drinking water at concentrations above 900 µg/L.According to the WHO, aluminum is commonly found in drinking water at concentrations above 900 µg/L. Aluminum is the third most abundant element in the earth’s crust.Aluminum is the third most abundant element in the earth’s crust.

15. The WHO relaxed (increased) the drinking-water guideline for boron (B) from 500 µg/L to 2,400 µg/L.The WHO relaxed (increased) the drinking-water guideline for boron (B) from 500 µg/L to 2,400 µg/L. The World Health Organization and Boron However, at least part of this increase was due to a rounding error.However, at least part of this increase was due to a rounding error. (Image by Theodore Gray)

16. The WHO relaxed (increased) the drinking-water guideline for nickel (Ni) from 20 µg/L to 70 µg/L.The WHO relaxed (increased) the drinking-water guideline for nickel (Ni) from 20 µg/L to 70 µg/L. The World Health Organization and Nickel (Image by Theodore Gray) The former 20 µg/L guideline protects against adverse kidney, liver, and reproductive effects from chronic or long-term exposure to nickel.The former 20 µg/L guideline protects against adverse kidney, liver, and reproductive effects from chronic or long-term exposure to nickel. In contrast, the current 70 µg/L guideline protects against skin eczema from a less likely acute or short-term exposure to nickel.In contrast, the current 70 µg/L guideline protects against skin eczema from a less likely acute or short-term exposure to nickel. This change was justified by an unpublished, industry-funded study done by a commercial laboratory; an interlibrary loan request for this study was declined by the industry group.This change was justified by an unpublished, industry-funded study done by a commercial laboratory; an interlibrary loan request for this study was declined by the industry group.

17. The most recent increase was calculated using a “no-effect group” with “no evidence of renal damage”.The most recent increase was calculated using a “no-effect group” with “no evidence of renal damage”. The WHO relaxed (increased) the drinking-water guideline for uranium (U) from 2 µg/L to 15 µg/L, and then from 15 µg/L to 30 µg/L.The WHO relaxed (increased) the drinking-water guideline for uranium (U) from 2 µg/L to 15 µg/L, and then from 15 µg/L to 30 µg/L. The World Health Organization and Uranium (Image by Theodore Gray) However, this nominal “no-effect group” was associated with statistically significant increases in diastolic blood pressure, systolic blood pressure, glucose excretion in urine, calcium fractional excretion, phosphate fractional excretion, and diuresis.However, this nominal “no-effect group” was associated with statistically significant increases in diastolic blood pressure, systolic blood pressure, glucose excretion in urine, calcium fractional excretion, phosphate fractional excretion, and diuresis.

18. The former 1 µg/L guideline was based on the toxicity of methylmercury, an organic and highly toxic form of mercury found in the environment.The former 1 µg/L guideline was based on the toxicity of methylmercury, an organic and highly toxic form of mercury found in the environment. The WHO relaxed (changed) the drinking-water guideline for mercury (Hg) from 1 µg/L of total mercury to 6 µg/L of inorganic mercury.The WHO relaxed (changed) the drinking-water guideline for mercury (Hg) from 1 µg/L of total mercury to 6 µg/L of inorganic mercury. The World Health Organization and Mercury (Image by Theodore Gray) The revised guideline is applied only to inorganic mercury.The revised guideline is applied only to inorganic mercury. This change did not take into account important research published during the last 10 years.This change did not take into account important research published during the last 10 years.

19. However, this increase did not take into account important research on selenium toxicity and children that was published during the last 15 years.However, this increase did not take into account important research on selenium toxicity and children that was published during the last 15 years. Similarly, the WHO relaxed (increased) the drinking-water guideline for selenium (Se) from 10 µg/L to 40 µg/L.Similarly, the WHO relaxed (increased) the drinking-water guideline for selenium (Se) from 10 µg/L to 40 µg/L. The World Health Organization and Selenium (Image by Theodore Gray) As a result, the current 40 µg/L drinking-water guideline for selenium does not protect children.As a result, the current 40 µg/L drinking-water guideline for selenium does not protect children.

20. No.Ele.ppmNo.Ele.ppmNo.Ele.ppmNo.Ele.ppm 12345678910111213141516171819OSiAlFeCaMgNaKTiHPMnFBaSrSCZrV455,000272,00083,00062,00046,60027,64022,70018,4006,3201,5201,1201,0605443903843401801621362021222324252627282930313233a33b35363738ClCrNiRbZnCuCeNdLaYCoScNbNGaLiPbPrB1261229978766866403531292520191918139.1939404142434445464748a48b505152535455a55b55cThSmGdErYbHfCsBrUSnEuBeAsTaGeHoMoWTb8.17.06.13.53.12.82.62.52.32.12.121.81.71.51.31.21.21.258596061626364a64b66676869707172a72b7475a75bTlTmIInSbCdAgHgSePdPtBiOsAuIrTeReRuRh0.70.50.460.240.20.160.080.080.050.0150.010.0080.0050.0040.0010.0010.00070.00010.0001 A Challenge for Drinking Water Scientists Abundance of elements in the earth’s crust. Elements with WHO drinking water guidelines are white. Only 14 of 76 (18%) elements in the earth’s crust have a WHO drinking water guideline. Many of the remaining elements are toxic and commonly found in groundwater. More guidelines are needed.Only 14 of 76 (18%) elements in the earth’s crust have a WHO drinking water guideline. Many of the remaining elements are toxic and commonly found in groundwater. More guidelines are needed.

21. A Second Challenge for Drinking Water Scientists 50,000 ng/L 10,000 ng/L 7,000 ng/L 170 ng/L 10 ng/L The maximum allowable concentration of As in drinking water set by the governments of most developing counties The maximum allowable concentration of As in drinking water recommended by the WHO and set by the governments of most developed counties The detection limit for measuring As in drinking water by the arsenomolybdate method Causes an unacceptable risk of death from skin cancer, according to the WHO Causes an unacceptable risk of death from all cancers, according to the Harvard School of Public Health

22. State, City, or Region of India Range of Uranium Concentration (μg/L) DelhiGhaziabad Himachal Pradesh, Bilaspur Himachal Pradesh, Chamba HimalayasHyderabadJhansiKanpur Karnataka, Kolar MaharashtraPunjab Punjab, Amritsar Punjab, Bhatinda Punjab, Malwa Uttar Pradesh West Bengal 2.2 – 8.8 4.2 – 11.4 0.1 – 4.6 0.3 – 6.8 1.1 – 35.8 0.6 – 82.0 0.9 – 6.4 3.3 – 9.1 0.3 – 1,442.9 0.03 – 7.8 0.5 – 579 3.2 – 45.6 11.7 – 113.7 5.4 – 43.4 1.4 – 19.2 1.3 – 13.2 A Third Challenge for Drinking Water Scientists The range of uranium concentrations in drinking water samples from various states, cities, and regions in India (Bajwaa, et al. 2015).

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