The Unshared Burden of Fluorosis Affected Women:
A Reflection from Bihar
 

Since time immemorial women have been described as complex and the more difficult to comprehend sex in prose and poems across cultures. While this is a controversial claim, there’s one claim about women that certainly cannot be contested – women have special healthcare needs that men don’t. As the gender which bears and rears the child, women have reproductive and overall health needs which are more intricate and challenging than men’s. The onus of providing this health cannot be on one ministry alone – the food we eat, the water we drink, the air we breathe, our health designing and delivering institutions, education system, and our collective conscience as a society – all of these determine the health that our women live in.

Fluoride affects women’s reproductive health by interfering with iron absorption rates of the body. Medical literature shows strong correlation between the accumulation of fluoride in the body and mild-moderate anaemia. (Fluorosis Research & Rural Development Foundation (FR&RDF), 2009; Del Bello, 2020). Anaemia in women and children is a shameful public health reality that our health system has been battling with. The case of Bihar in this regard is a prominent example.

Fig. 1 shows percentage of pregnant women with any kinds of anaemia during 1989-2020, in Bihar. There’s enough evidence in public health and medical literature that anaemia during pregnancy leads to high-risk births, thus increasing maternal and child mortality, and malnourishment among children born to such mothers (Ministry of Health and Family Welfare, 1999, 2006, 2020b).

Some of the measures available to improve health of pregnant and lactating women in rural areas include six Ante-Natal Check-ups (ANCs) to be done at the Aanganwadi/community centre, distribution of Take Home Ration (THR), and eleven home-visits by ASHA and Aanganwadi worker to the child’s home in first two years of child birth. However, as someone who has worked for two years in Samastipur district of Bihar on strengthening government institutions to reduce maternal and child mortality, I can vouch that all these programmes are under-delivering even more gravely than the government data reports. The ANCs never happen properly because frontline workers are not trained well-enough and don’t have the necessary medical equipment to deliver them, the THR is consumed by the entire family and not just the pregnant woman, and the Iron and Folic Acid (IFA) tablets which are to be given free of cost to pregnant women are never in full supply, and upon being received are not consumed because the community knowledge on (side) effects of their consumption is sketchy.

Not far from Samastipur is the district of Gaya. There’s a village called Churaman Nagar which, like most of Bihar, has poor NFHS-reported health indicators. (Ministry of Health and Family Welfare, 2020a). But the village has an additional problem – that of high levels of fluoride in drinking water (Ray, 2020). While the safe limit of fluoride in drinking water is 1 ppm, the village has about 10-16 ppm of fluoride (Awasthi, 2020). The intensity is of problem is grave enough to leave about half of its population with dental and skeletal fluorosis, a progressive-crippling condition. The decentralised water treatment technology doesn’t get repaired on time, alternative source of drinking water is not available, and residents find it hard to access medical treatment.

Now imagine the burden of the collective failure of our institutions on the health of women in this scenario. From accessibility to nutrition to medicines to drinking water, we are failing our women at every juncture. As many as 76% of children in the age of 6-59 months in Gaya are anaemic, and this figure is 64.4% for pregnant women in Gaya. (Ministry of Health and Family Welfare, 2020a). The NFHS doesn’t report data on fluorosis, and detection of skeletal fluorosis is in itself a challenge for doctors because of its similarity to several other skeletal disorders.

The need of the hour is, hence, to design solutions that let people own them. One such way is to deliver decentralised water quality testing and treatment solutions. Development Alternatives is developing de-fluoridation kits and their need cannot be overemphasised. Another important aspect here is to increase people’s scientific understanding of concepts. When scientists co-create knowledge with people, it’s called ‘citizen science’. Through our project experience in Udaipur on citizen science for integrated water resources management, we believe that it is a more organic way of achieving behaviour change. Along with provisioning of technology, we have to work towards educating the people and strengthening government institutions to keep delivering change on ground.■

References:

Awasthi, P. (2020) ‘Life in a “cursed” land during a pandemic: The story of Churaman Nagar - The Week’, The Week. Available at: https://www.theweek.in/news/india/2020/06/07/life-in-a-cursed-land-during-a-pandemic-churaman-nagar-bihar.html (Accessed: 31 December 2021).

Del Bello, L. (2020) ‘Fluorosis: an ongoing challenge for India’, The Lancet Planetary Health. The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license, 4(3), pp. e94–e95. doi: 10.1016/S2542-5196(20)30060-7.
Fluorosis Research & Rural Development Foundation (FR&RDF) (2009) Anaemia In Pregnancy. Available at: https://fluorosis.foundation/anaemia-in-pregnancy (Accessed: 31 December 2021).

Ministry of Health and Family Welfare (1999) National Family Health Survey 2 - Bihar.

Ministry of Health and Family Welfare (2006) National Family Health Survey 3 - Bihar.

Ministry of Health and Family Welfare (2020a) National Family Health Survey - 5 - District Fact Sheet Gaya, Bihar.

Ministry of Health and Family Welfare (2020b) National Family Health Survey 5- Bihar.

Ray, U. K. (2020) ‘Ground Report: Why Is Bihar’s Fluoride Contamination Problem Not a Poll Issue?’, The Wire. Available at: https://thewire.in/rights/ground-report-bihar-water-flouride-contamination (Accessed: 31 December 2021).

Till, C., Green, R., Grundy, J. G., Hornung, R., Neufeld, R., Martinez-Mier, E. A., Ayotte, P., Muckle, G., &Lanphear, B. (2018). Community Water Fluoridation and Urinary Fluoride Concentrations in a National Sample of Pregnant Women in Canada. Environmental health perspectives, 126(10), 107001. https://doi.org/10.1289/EHP3546
 

Ekansha Khanduja
ekhanduja@devalt.org