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The Guardian, 9th / 17th July, 1998.
Fred Pearce travels to central India to unravel the origins of a crisis new threatening tens of millions of people worldwide
Meet 10-year-old Shatap, with a walk straight out of Monty Python. But this diminutive figure is not playing games as he waddles up the muddy lane, his knees locked together and his stunted and misshapen lower legs splayed wide like flippers. His gait is permanent; his hones grossly deformed by fluoride in drinking water pumped from a borehole at the bottom of the lane.
THE PUMP was installed in Shatap's village of Hirapur, in the central Indian state of Madhya Pradesh, during the UN's International Water Decade of the 1980s. Its borehole was one of the millions sunk worldwide in a highly publicised race to provide the world's poor with 'safe' drinking water, planned and part-funded by aid agencies such as the UN Children's fund, Unicef.
The underground water was indeed mostly free of the bacteria that can infest polluted surface water. But nobody ever tested the underground water for natural chemicals, such as fluoride, even though they were known to be widely present in rocks from which the water was pumped. Madhya Pradesh itself is famous for its rich mineral deposits.
"The. problem is enormous, unbelievable", says Andezhath Susheela of the Fluorosis Research and Rural Development Foundation in Delhi. She has been unravelling the national story for a decade during which time her estimate of the people leading "a painful and crippled life" from fluorosis has risen from one million to 25 million and now to 60 million - six million of them children - spread across tens of thousands of communities. "In some villages three quarters of the population are seriously affected."
The first rains of this summer's monsoon are beginning to fall as Shatap and his friends assemble in the yard of the Hirapur village head, Chudaman Bhavre. Almost all of them are knock-kneed and have the brown-stained teeth characteristic of the first stages of fluoride poisoning. They drank water from a poisoned pump while attending the village primary school close by. Fluoride levels in the water were 11 times the safety limit of one part per million.
The children who lived nearest to the pump and drank its water continuously have suffered most. Besides Shatap, there is Kamala and her bow-legged sister Krishna, both daughters of the village head. Aged 14 but looking no more than nine, Krishna was forced to abandon schooling because her deformed limbs could no longer take her to the secondary school in a neighbouring village.
Many parents, including Krishna's mother, suffer painful, stiff and misshapen backs and hips, and chronic gastro-enteritis.
Bhaskar Raman, a local activist who brought the village's plight to the attention of doctors, says there has been an epidemic of stillbirths and involuntary abortions - all known symptoms of fluoride poisoning.
All across Mandla, a district of a million or so people in eastern Madhya Pradesh, a steady stream of children have reported similar complaints since the late 1980s. But in this remote corner of central India, doctors hadn't heard of fluorosis. They instead diagnosed arthritis, polio, rickets, a genetic fault or simply a "mystery disease".
The link with water was never made. Until, that is, Tapas Chakma, a young research officer at the Regional Medical Research Centre in Jabalpur came to the village of Tilaipani in 1995 and suggested that a local girl's strange disease might be fluorosis.
Initially, he was rebuffed by local officials. "I asked the Pollution Control Board about the water here, and they assured me it was safe", Chakma recalls. "I didn't accept that and sent a water sample to Delhi, which revealed the truth." Soon he began to hear about other villages with similar problems, and he demanded a district-wide screening of water.
Three years later, engineers have dismantled more than 500 pumps in more than 300 villages in Mandla to prevent people drinking the poisoned water.
Chakma's boss at the medical research centre, Ravi Shankar Tiwary, says "some of the blame lies with aid agencies such as Unicef".
These bodies lobbied for and helped fund the boreholes-and-handpumps programme "But I also blame the public health engineers in Mandla for what has happened. They dug the wells. They said at first that they had tested the water. But they didn't. I know. They didn't have the right equipment."
The whiff of corruption hangs over the Mandla story. Raman alleges that private contractors sank boreholes deeper than necessary as part of a scam to milk the public purse. He says that 30 metres would have been deep enough - a figure borne out now, at the end of the dry season, when open wells in the village contain water at depths of between just 15 and 20 metres. Sinking the boreholes to 50 metres increased the value of the contracts, Raman says, but it also penetrated the fluoride-bearing rocks that were only present at these lower depths.
Officials at the Mandla department of public health engineering brush off enquiries, even from Unicef, which has sought to repair damage by offering to install some trial defluoridation equipment. "In Mandla, the administration is so terrified they won't let us go near", says Vishwas Joshi, Unicef's water project officer in Delhi.
But Mandla's tragedy is a tiny part of a vast landscape of ignorance, confusion and indifference that is crippling millions in the state of Madhya Pradesh and beyond. A decade ago, government scientists named 12 districts in the state, including Mandla, as being at risk from fluoride in water. To date, only Mandla's wells have been fully surveyed. But the more the scientists look, the more they find. Just last month, dozens of pumps were shut in neighbouring district of Dindori. The local press reported panic as engineers took away pump handles without offering an explanation to villagers. In one village, Bichia, water was almost 13 times the safe limit.
It now seems incredible that so much poisoned water should have been tapped for drinking under a UN programme to provide safe water. The first instances of fluorosis in areas where underground water contained high fluoride levels were recorded in India 60 years ago. The governments health ministry listed hot spots in several states where villagers suffered fluorosis from water in 1962. A task force to educate doctors and engineers was formed in 1986. Gourisankar Ghosh, who as head of India's National Drinking Water Mission warned about the problem to little avail in the late 1980s, says: "There should have been far greater vigilance. We were sinking 60,000 boreholes a year and analysing water from at most a tenth of them."
Since then geologists have devoted much time to plotting fluoride-bearing rocks. They have established that fluoride is associated with weathering granite rocks, and with water low in calcium. Gunnar Jacks of Sweden's Royal Institute of Technology found that fluoride levels are highest in valley bottoms. Five years ago, he and geologists from the Central Ground Water Board of India recommended siting wells further up hillsides. Yet few doctors or water engineers in India seem to have heard of this.
Lack of communication is endemic, says Susheela of the fluorosis research foundation. "Engineer's presume that underground water is clean so they don't diagnose it."
What now? Digvijay Singh, Madhya Pradesh's chief minister has announced plans to defluoridate water. That was two years ago, and there's still little sign of progress. In Hirapur, engineers have laid new water pipes but have not yet connected them to a new source. As a result, villagers have started to use an ancient open well, hauling buckets of water from a reservoir just as open to pollution from the surface.
Many people now believe that water from the poisoned boreholes could have been used for washing, with the cleaner boreholes reserved for drinking water, says Raman. For its part, Unicef has backed efforts to treat water to remove fluoride as it is pumped to the surface. Early techniques were too expensive to sustain, and most defluoridation. equipment installed over the past decade is out of action. Unicef is now testing a low-cost kit for homes.
Meanwhile, India's escalating water crisis, which is forcing people to search for water deeper and deeper underground, is exacerbating the problem. "When you pump water from deeper underground, you are tapping older water, water which has been in contact with the rocks for longer. So it is more contaminated", says Joshi. As the water tables continue to fall in response to demand, fluoride levels in thousands of boreholes, many of them still untested, will continue to rise.
When the village tap is contaminated
TILAIPANI is like tens of thousands of Indian villages. Half a kilometre from the nearest road, and set in fields strewn with quartz stones, its economy runs on cattle, whose milk is sold in its main town, 12 kilometres away. But a few years ago, cattle drinking from new boreholes sank by the department of public health engineering became crippled. Then the humans began to suffer, too.
It was here that Tapas Chakma, a young researcher, first uncovered the hidden epidemic of fluorosis across Mandla district. His studies, published last year in the journal Indian Paediatrics, found cases of severe knock knees in half of children under 20 years old in the village. In many cases the upper arm and the leg below the knee were splayed outwards.
The highest rate of deformity, 70 per cent, was among six to 10 year olds, who were toddlers when the new pumps first replaced surface wells. In the worst cases, he says, spines become entirely rigid and legs are so bowed inwards that they are permanently crossed.
Since 1996, all the handpumps in the village have been shut. A newly sunk borehole works only a few hours a day. As a result, women have resumed their age-old trek to fill buckets front a distant water hole.
Have the victims been offered help? Some children receive a "scholarship grant" of 150 rupees a month (about £2) by way of compensation. No-one knows if they'll still get the money when they can't get to school.
Fred Pearce listens to Unicef's excuses for the avoidable catastrophe
From bad to worse
FLUORIDE IS a worldwide menace. Last week, we reported how an estimated 60 million people in India suffer from fluorosis caused by drinking underground water, most of it brought to the surface by handpumps installed in the past two decades. But excessive natural fluoride is present in underground water supplies in at least 20 other countries. This is what Gourisankar Ghosh, who runs Unicef's worldwide water operations from its NewYork headquarters, will tell an international fluoride conference in Chile later this year.
The poison gushes to the surface from Chile to China, where there are an estimated 1.6 million victims, and from Ethiopia to Uzbekistan. "Wherever you have volcanic rock and acidic water, and people drink underground water you may have a problem", says Ghosh.
Handpumps installed during the UN International Water Decade of the 1980s gave villagers control over their own water supply, and freed them from reliance on either polluted surface waters or expensive networks of pipes bringing water from distant sources. But the handpump became a victim of its own success. The water decade, aimed ambitiously at producing safe and accessible water for all by 1990, became a race to sink as many wells as possible as quickly as possible. India set its own tough target of at least one water source for every 250 people, no more than a mile from any community.
Andezhath Susheela of the government's Fluorosis Research and Rural Development Foundation in Delhi says the backers of the water decade inculcated "an obsession with targets". This, she says, ensured that engineers arrived, sank their wells and then departed, testing little and leaving nobody to oversee the quality of water emerging from those wells.
The drive to bypass effluent at the surface encouraged engineers to plumb deeper groundwater, which is more vulnerable to geological pollution. Ravi Shankar Tiwary, director of the Regional Medical Research Centre in Jabalpur, India, says "aid agencies such as Unicef should have known of the risks, but did not issue warnings."
In India, Unicef in particular cannot escape its share of responsibility for what happened. It sunk relatively few wells itself, but it claims to have "set the agenda" by formulating plans, promoting pump designs and encouraging the Indian government to speed up the programme and reduce costs by employing private drilling contractors to sink the wells. You still have to scan the fine print of Unicef's glossy brochures with great diligence before finding any passing reference to the problems that resulted. In a recent 50-page booklet on Unicef's water work in India, the fluoride problem merited just two paragraphs.
But officials on the ground do now admit their errors. "Yes, it became a numbers game", says Rupert Talbot, who runs water policy for Unicef in Delhi. "When you are driven by demand, quality is inclined to slip. Contractors got away with murder."
It was, he says, never possible for government officials to check whether boreholes were sunk to the right depth, protected from pollution, or had their water tested on completion. In such an environment, he says, "safe" is a very questionable term to describe water from underground sources. He estimates that at least one handpump in every 10 is today contaminated with unsafe levels of natural chemicals, mostly fluoride and arsenic, but also iron and salt.
Many water specialists, including some within Unicef, now argue that surface water sources should not have been so wantonly abandoned. Rather, they should have been renovated and made safe. India has a rich tradition of techniques of water harvesting, for instance, capturing clean rainwater from rooftops, hillsides and valleys.
For many years, rainwater harvesting has been a hobbyhorse of a few academics and environmental campaigners, such as Anil Agarwal, director of the Centre for Science and the Environment, in Delhi.
But the idea of reviving and improving these water sources to meet modern needs is now gaining ground. Even Unicef is now having a change of heart. Talbot says: "I think there is a lot to be said for sticking with the old water sources, such as shallow wells and rainwater harvesting, provided they can be made safer, for instance by keeping animals away."
Clearly, in India and elsewhere, the handpumps of the International Water Decade brought real benefits to millions of people. They can take a large share of the credit for a dramatic reduction in cases of dysentery and of parasites such as guinea worm, which once infested many open wells but is now virtually eradicated from the country.
But the wholesale promotion of handpumps as a cheap panacea to meet ambitious international targets has in many places proved disastrous. As Joshi puts it: "More enthusiasm for water quality and less for a pursuit of quantity at all costs would have left many more people with safe drinking water today than is the case." Millions of children limping round their villages would agree.
Nutrition is the key to healthy bones and teeth
IN BRITAIN, the Department of Health says the "optimum" fluoride dose for water supplies is 1 part per million. But in one Indian village studied in detail, Bhanakpur near Delhi, water with between 0.7 and 1.6 ppm of fluoride was enough to leave 17 per cent of the population suffered from the bent bones of skeletal fluorosis.
So should you worry? Have the anti-fluoride campaigners, often dismissed as cranks by the health establishment in Britain, been right all along? Does fluoride's undoubted success in fighting tooth decay have a literally crippling side effect?
Some countries show more concern at the risks than Britain. In Sweden, for instance, fluoride toothpaste tubes carry a warning that children under four years should not use them. British warnings simply say under-sevens should use no more than a pea-size piece of paste. But TV toothpaste adverts routinely show people using far more.
Some recent studies have shown cases of dental fluorosis (mottled teeth) in children in Birmingham. In Hungary, researchers have found epidemics of hip fractures among the elderly in areas with fluoridated water supplies, though the link is far from proven.
The good news is that there is plenty of evidence that the amount of fluoride absorbed and retained by the body is very dependent on nutrition, especially for children. A well-fed child consuming plenty of calcium, and vitamins A and C should riot be at risk from the sort of fluoride doses that can cripple a child in India. Calcium, in milk for instance, is a good defence because the body will absorb it in preference to fluoride, building strong fluoride-free bones.
The science of fluorine
Fluorine is the 13th most abundant element in the Earth's crust where it exists in the form of fluoride minerals and salts, such as aluminium fluoride (topaz) and calcium fluoride (fluorspar). Fluorides often turn up as a constituent of granite and may from rich seams as the granite is eroded. The fluorides in these rocks will dissolve in water but they can reach high concentrations when underground water sits in pores in the rocks for long periods.
How it affects the human body
Simple chemical treatment can remove fluorides from water supplies. One method is to add lime and alum, a complex sulphate of aluminium and potassium, which make the fluoride salts coagulate. Another is to add aluminium oxides which will absorb the fluoride ions.
There is growing evidence that fluoride ions also damage soft tissues, including muscles, the gut and organs such as the kidney. The symptom of these soft-tissue effects, including gastro-enteritis, can be reversed when patients drink clean water. But any damage to the skeleton is permanent.
Our (IMPORTANT) Notes:
 There is no good evidence to say that ingested fluoride does not reduce tooth decay. In fact, the opposite could be argued;
 We do not know of any use of sodium fluoride in water fluoridation supplies in the UK. hexafluorosilicic Acid is commonly (if not exclusively) used in water fluoridation schemes in the UK;
 Trying to remove fluoride from water can be dangerous and may make the resulting 'concoction' more dangerous to drink. Only professional filtration systems are recommended;
 Long-term soft tissue damage will depend on various factors. Specialist advice will need to be sought.