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Posted by Dr. Sushrut Jangi July 24, 2013 08:54 AM
I'm not used to seeing public health stories about India in American newspapers - but last week, the tragic deaths of 23 North Indian children after they ate tainted school lunches in the agricultural state of Bihar was prominently featured in the New York Times, CNN, the Washington Post, NPR, and the Boston Globe. Such extensive American media coverage about a health tragedy in a poor, rural state in India surprised me. Obviously, the death of children arouses our compassion, but unfortunately, such events occur so regularly throughout the developing world that most end up receiving notably less attention.
Consider an event in Nigeria three years ago: a medical team belonging to Doctors without Borders ventured into northwest Nigeria to conduct an immunization campaign for children but instead found farming towns mysteriously devoid of children altogether. The team found families engaged in subsistence gold mining, a process that released dust laden with unbelievably high concentrations of lead. Partnering with local agencies, the Centers for Disease Control, and the World Health Organization, researchers determined that the lead exposures were among the highest in the world - and that such exposure had killed more than 400 children under age 5 and left more than 2,000 children with permanent disabilities.
But when I asked some colleagues about these two stories - the 23 dead in India, and more than 400 dead and 2,000 disabled in Nigeria - most were very aware of the school-lunch story but had no familiarity with the second. The reason for this discrepancy, I suspect, rests on the speed of the two tragedies. Moments after the Indian children noticed a funny taste in their food - apparently from a potent insecticide -- many developed stomach cramps and vomited; within hours, some were critically ill or had died, even before reaching the hospital. Within a day, news agencies around the world were alerted to the crisis.
On the other hand, in Nigeria, the lead poisoning epidemic has evolved over months to years, and the consequences of lead poisoning - brain damage, paralysis, deformity - have taken a long time to reveal themselves. Consequently, the Nigerian story, although tragically important, has been more difficult to tell in our current rapid pace of media coverage. Without reminders, the slow-moving public health crisis tends to slip under our radar. Even in the recent news about the poisoned schoolchildren in India, a slower story hides in its shadow.
"You've heard about the cancer train?" asks Amit Khurana, head of the Food Safety and Toxins Program at the Center for Science and Environment in New Delhi, India. Nightly, he says, a train departs from a farming district in Punjab, taking passengers to a hospital in the bordering state of Rajasthan. The train is nicknamed "marizon ki train" or "train of the ill": its seats routinely fill with cancer patients, both young and old, afflicted with all manner of malignancies. The reason for high cancer rates in this rural farming community?
"We found that people living in this district and the surrounding areas had high levels of pesticides in the blood," Khurana says. Researchers discovered farmers were spraying crops with abnormally high concentrations of pesticides and rarely wore protective masks. And, just like the school in Bihar, empty pesticide containers were frequently used for storing food. But the doses of pesticides were not high enough to kill, as they did in the schoolchildren. Instead, people living in these farming communities developed disease slowly, over months to years. In fact, throughout the country, Indians have now been found to have high levels of pesticides in blood, skin, hair, nails, and even in the bone marrow.
And here, again, is the crux of the problem in a slow-moving disease process: the longer the time-lag between a potential exposure and its health consequence, the harder it is to track, to prove, and to report. "So a lot of people in India remain unaware of chronic pesticide exposures," Khurana explains. "A few years before I took this job, I didn't know about it either."
Now, Khurana is intimately familiar with chronic pesticide poisoning in India. Over the past decade, his NGO has found signs of high pesticide concentrations throughout the Indian marketplace. More than 17 brands of bottled water tested in New Delhi, for instance, contained almost 40 times the standard limit of pesticide concentrations. Similarly, in Pepsi and Coke bottled in India, the group found 30 - 36 times the recommended levels of pesticides.
Although two governmental bodies have since formed to try to regulate the registration, sale, and use of pesticides in agriculture, the implementation of such regulations has proven difficult. Monocrotophos, the chemical found in the school in Bihar, is banned in the United States and the European Union, but farmers in India routinely spray it on rice paddies even though the government has restricted its use. "What a farmer does has got nothing to do with the regulations of the state or central government," Khurana says. "He is more likely to be influenced by the sales representatives of the pesticide companies. Most farmers aren't even aware of the dangers of pesticides, how much they should use, or how long they should wait before bringing a sprayed crop to the market."
In the United States, we've been pretty good about regulating pesticides. Production and use of highly toxic organophosphates - including monocrotophos - have been curtailed. Acute pesticide poisonings, like the one in Bihar, are rare in this country. But the possibility of slow, chronic diseases from low-level absorption of pesticides are still possible. "There have been several prospective studies that show a relationship between pesticide levels in pregnant women and lower IQ levels in children," says David Bellinger, professor of neurology and environmental health at the Harvard School of Public Health.
In other words, he agrees with the idea that low, chronic pesticide exposure can adversely affect human health over time, with accumulating evidence connecting pesticide exposure to neurotoxicity in children and cancer risk in adults. Given more effective regulations in the United States, chronic pesticide exposure is less of an issue in our country, but Bellinger says that "we still have a way to go." Meanwhile, in India, this slow poisoning continues unchecked, and with a large pesticide industry lobby, no effective government regulations have been set into place.
I ask Khurana: if I go into any market in an Indian city and I buy a piece of fruit or vegetable, what are the chances that it will contain significant levels of pesticide? "One hundred percent," he says.
Maybe all this reporting of the tragedy in Bihar, I tell Khurana, might push the government to make changes, so this doesn't happen again.
"Maybe," Khurana hopes.
But the Indian media, he says disappointingly, has already moved on.
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About the authorSushrut Jangi is an internist at Beth Israel Deaconess Medical Center and an editorial fellow at The New England Journal of Medicine. More »
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