Arsenic poisoning of rural poor Bangladesh

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Arsenic poisoning of rural poor Bangladesh

An integrated framework to address the problem and possible solution

strategies

Expert: Crelis Rammelt Tutor: Jaap Rothuizen Coordinator: Coyan Tromp Course: Interdisciplinary Project Authors: Imme Groet (10050329),

Hugo van Mens (0582115) & Martijn Savenije (10002429) Version: 0.2 Words: 5529 Date: 07-11-2013

Abstract Chronic arsenic poisoning in Bangladesh through contaminated drinking water results in a major public health burden, especially for the rural poor segment of the population. An interdisciplinary literature research has been performed and data from field research of the Arsenic Mitigation and Research Foundation (AMRF) was used to explain differences in health outcomes and find solution strategies. Differences in health outcomes can be explained by integrated public health models that are fed by data from various disciplines. Integrated strategies, that address the multiple determinants of health, are necessary to solve the problem.

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1. Introduction

In the late 70’s the infant mortality rate in Bangladesh ranked among the highest in the world. This was the result of infected surface water, consumed as drinking water by the population. In an effort to reduce infant mortality UNICEF and the World Health Organisation (WHO) launched a program in Bangladesh aimed at providing access to potable water by installing tube wells that were capable of reaching groundwater (Howard, 2009). In the 1980s, however, it was first detected that groundwater in Bangladesh was contaminated with naturally occurring high levels of arsenic (Ng, Wang & Shraim, 2003, p. 1356). It is currently recognized that the contamination has resulted in one of the largest mass poisonings through contaminated drinking water in human history.

‘Acute high-dose exposure to arsenic can cause severe systemic toxicity and death.’

(UpToDate, 2013). Chronic arsenic poisoning is associated with various diseases, including hyperpigmentation, keratosis, cardiovascular disease, respiratory symptoms, diabetes, neuropathy and carcinoma (Medscape, 2013; Ng, Wang & Shraim, 2003; Rammelt, 2012; UpToDate, 2013). See Figure 1.1 and 1.2. World Health Organization (WHO, 2013) guidelines recommend a maximum of 10 micrograms of arsenic per liter of water. For Bangladesh in particular ‘where arsenic contamination in the groundwater has reached a very alarming level’ (Ng, Wang & Schraim, 2003, p. 1357), it is recommended to dig wells to alternative aquifers with less arsenic concentration, or use technologies such as rainwater harvesting, water filtration or arsenic precipitation. Howard (2003) explains that the risks of microbial contamination of

drinking-water have been substituted for the risks of arsenic contamination of drinking-water in Bangladesh, although risks from microbes are greater. While microbial hazards lead to acute health attacks that can be fatal to vulnerable groups, arsenicosis develops over a longer time-period. In the past thirty years, solutions to the arsenic contamination problem have been proposed and executed. However, current attempts to combat the issue have proven to be inadequate. Furthermore, drinking water from many households still exceed WHO guidelines and many tube wells have not been tested in the past 6 years (Sarker, 2012). Seen Figure 1.3. This research is a proposition for an integrated solution for the prevention and treatment of arsenic contamination in Bangladesh.

This research has a scientific relevance due to the integrated character and interdisciplinarity of this research. To integrate insights from various disciplines that previously work in isolated fields on the same problem. This research has a scientific relevance due to the integrated character and interdisciplinarity of this research. The disciplines are varied and have a broad spectrum on the problem. It proposes a theoretical framework for a possible future solution, which could be taken in consideration when solutions programs for arsenic contamination in

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Figure 1.1: Depigmentation (Rammelt, Masud, Boes & Masud, 2011, p. 24)

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1.1 Research question and research goal

Our main research question with regard to the arsenic contamination problem in Bangladesh is as follows:

“What solution strategies to resolve the arsenic-related public health burden will fit the needs of the rural poor population in Bangladesh in terms of their health condition, and will fit their social, economic and physical constraints enforced by their environment?”

Regarding the arsenic-related public health burden in Bangladesh and the main research question above, the following sub questions have been formulated:

● What are the influences or limitations of policy on the determinants of health?

● What are the influences or limitations of external developments, including demography, economy, socio-cultural developments, technology and geography on the determinants of health?

● What are the influences or limitations of the health care system on the determinants of health?

● What are the influences or limitations of the health condition on external developments and prevention and care?

● What solution strategies are feasible?

Feasibility here is understood as being an accessible and effective solution to influence the determinants of health of the rural poor population in Bangladesh. Thus, approaches that have proven to be effective and that are able to reach the rural poor will be selected to answer the main research question.

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.

Figure 1.3: Map of arsenic contamination of household drinking water in Bangladesh in 2009

(Sarker, 2012, p. 1235)

Prior research shows that variations in the severity of health effects caused by the arsenic contamination exist (Rammelt et al., 2009). The main goal of this research is to synthesize general solution strategies using a local case study. It is the belief of the researchers of this report that by analyzing the local situation in these two villages, general solution strategies and principles can be developed that can be of benefit to populations suffering from arsenic

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Figure 1.4: Overview of the involved disciplines

1.2 Justification for using an interdisciplinary approach

The problem with regard to arsenic contamination of drinking water in Bangladesh can be considered as an interdisciplinary problem. This particular problem fits the four requirements for an interdisciplinary problem, as found in Repko (2012, pp. 85-86). Interdisciplinary problems are complex and require a different approach with an integration of varied perspectives into one solution. This problem is complex for several reasons. Firstly, water, by nature, is a complex issue. It does not stick to borders, single disciplines or adhere to local regulations. Secondly, the drinking water issue in Bangladesh involves many interacting stakeholders: local civilians, hospitals, governments, companies and NGO’s. Thirdly, no single discipline was competent to propose a successful solution. The effect of arsenic on human health has been studied by medicine, while sanitary engineering has developed technologies to produce potable water. Business studies has developed methods to successfully complete projects, to perform

willingness to pay studies and to manage risks, while human geography has developed methods to study humans within their cultural background and their relationship with the geographical environment. Several disciplinary approaches have been adopted to solve the problem, without succes. This research is a solution based research, with an interdisciplinary approach. Each discipline only tackles a single aspect of the problem, which currently did not lead towards a feasible solution. This research will be based on three important disciplinary approaches.

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Important insights could be obtained in causes and relations of a various of disciplines. This is visualised in figure 1.1. Non-disciplinary perspectives are also considered.

1.3 Critical assessment of choices and limitations

Early on it was decided that the scope of this report would be broad. The complexity of the problem demands a solution that is not limited to a single aspect (e.g. improved doctoral care), but a solution that works on several levels. In order to achieve this a comprehensive public health model was used. This model provides a framework in which it becomes clear just how each aspects influences another, and on what level this influence is found.

This report also has a number of limitations. Firstly, the time period to conduct research was rather limited. This was a problem, especially with regard to the broad scope of the project. A possible consequence of this is that some aspects may not get the required attention in order to provide a complete assessment. Secondly, the researchers were limited to second and third grade resources due to the fact that it was not possible the research site as part of this project. As such, this report is based on available literature and an interview with an on-site researcher rather than first hand research.

1.4 Report structure

The research is constructed as follows: in the next chapter a theoretical framework is given. The theoretical framework provides a description of the relevant theories and

concepts of the three disciplines as a framework for the research. The following chapter is a description of the methodology, which contains the comparison between the two villages as indicators for the differences between the contaminated villages and if an integrated solution could take these differences into account. The public health model is presented. The results are presented and discussed within the framework of the public health model. The conclusion follows the results and gives the main findings of this literature research. The discussion finishes the report.

2. Theoretical framework

The theoretical framework consists of two components: (1) a general description of the Determinants of Health model and its parts that are related to (2) a discussion on several theories from the business, human geography and medical informatics disciplines.

2.1 Determinants of health model

The determinants of health model of the Dutch Institute for Public Health and the Environment (RIVM, 2013) is used as theoretical framework to frame the issue of arsenic poisoning in

Bangladesh. It shows the influence of policy, external developments, prevention and care on the determinants of health of individual persons or populations. The health conditions (or health outcomes) of these persons or populations are again determined by the determinants of health, and the prevention and care they receive. See Figure 2.1. In this chapter we will explain each part of the model in more detail and relate it to theories from the respective disciplinary literature reviews. Figure 2.2 provides the complete detailed view of the model.

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Lalonde stated in the 60s that health care policy was merely aimed at care and cure, while the health of the population is also determined by other factors, such as the social and physical environment and personal lifestyle (Mackenbach, 2008). His model has been developed further within the discipline of public health. We chose the model of the RIVM because it has been successfully applied in Dutch policy-making and addresses the various aspects that are important in the arsenic related public health burden in Bangladesh.

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Figure 2.2: Detailed framework (freely translated and adapted from RIVM, 2013)

2.2 Health condition

Figure 2.3: Health condition

The health condition can be understood in terms of diseases and disorders, functioning, quality of life, mortality and healthy life expectancy. This incorporates several aspects from the

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functioning is related to capability to generate income (business), and quality of life is related to resilience (human geography). WHO (2013) defines health generally as ‘a state of complete physical, mental and social well-being and not merely absence of disease or infirmity’. However, Huber et al (2011, p. 2) based a new definition of health ‘on the resilience or capacity to cope and maintain and restore one’s integrity, equilibrium, and sense of wellbeing’. The proposed definition is: ‘the ability to adapt and self manage [...] for the three domains of health: physical, mental and social’. See Figure 2.4.

Figure 2.4: Definition of health by Huber et al (2011) as ‘the ability to adapt and self manage’

2.3 Determinants of health

An individual’s health condition is determined by its direct physical environment, social environment, lifestyle, and personal factors.

The physical environment includes land, air, water, plants and animals, buildings and other infrastructure, and all of the natural resources that provide human basic needs and opportunities for social and economic development. To an extent the physical environment can be part of the social environment (New Zealand Ministry of Social Development, 2003). In the framework

discussed here, however, the physical environment is limited to the immediate physical surroundings of an individual. The social environment encompasses the immediate physical surroundings, social relationships, and cultural milieus within which defined groups of people function and interact. The social

environment subsumes many aspects of the physical environment, given that contemporary landscapes, water resources, and other natural resources have been at least partially configured by human social processes. Embedded within contemporary social environments are historical social and power relations that have become institutionalized over time. Social environments are dynamic and change over time as the result of both internal and external forces. There are relationships of dependency among the social environments of different local areas, because these areas are connected through larger regional, national, and international social and economic processes and power

Figure 2.5:

Determinants of health

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relations (Barnett & Casper, 2000). Lifestyle is a broad term and is defined in the simple definition: a distinctive, hence recognizable, mode of living composed of sets of activities and practices (Stebbins, 1997). Personal factors include aspects such as genetic.

These factors are influenced by policy, external developments, prevention and care, as discussed below.

2.4 Policy

Health (care) system policy is related to the prevention and care that is provided. In general, policy can address various determinants of health (such as the physical and social environment) and external developments (such as technology).

Figure 2.6: Policy

‘Other policy areas’ in the figure can be interpreted as the state. The state in this report is defined in terms of the theory of the neutral state in capitalism. This catalogue demonstrated the dependency of life of the population on public goods, such as health care, schools, police, waste disposal etc. Clark and Dear added in 1984 that the state functions as a regulator and facilitator. Within all of these functions, the neutrality of the state is broadly assumed, that is, the state is not in conflict or biased towards a specific segment of the population (Flint & Taylor, 2007, p. 137-138). The theories of the neutral state in capitalism provide a framework from a top down point of view on the available solutions for the arsenic contamination problem.

‘Health care system’ is defined according to the medical dictionary (2008) as ‘the complete network of agencies, facilities, and all providers of health care in a specified geographic area. Nursing services are integral to all levels and patterns of care.’ Health care is a facilitation of the state.

Policy also includes policy at other levels than the state only, such as community based organizations. These organizations tend to be both policy makers and implementers.

2.5 External developments

Developments external to the determinants of health can be shaped by policy and health conditions of a population. They include demography, economy, social-cultural developments, technology and geography. See Figure 2.7. Integrated concepts are involved with the external development, as explained below.

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Figure 2.7: External developments

Poverty

An important element in economic, social-cultural development and technology is the concept poverty. Poverty was primarily described as an economic concept, well known as absolute poverty. The World Bank defined the poverty line in 1990 on $1 per day (Ravallion et al., 2009). Due to critique on absolute poverty, the concept relative poverty was defined (UNESCO, 2001). Currently, the millennium development goals have the broad (interdisciplinary) concept of poverty defined in a set of eight goals; not sufficient access to food, no access to primary schools, gender inequality, high child mortality rate, high rates of Malaria, HIV, AIDS and other diseases, bad maternal health, no environmental sustainability and no global development partnership (UN, 2013; Shapiro, 2004).

2.6 Prevention and care

Prevention and care are determined by policy and individuals’ health conditions. Prevention of disorder, disease and death can be divided into health protection that addresses the physical environment (such as clean drinking water), health promotion that addresses lifestyle (such as diet) and disease prevention that addresses personal factors. Health care and cure interventions address individual’s personal factors and their use and costs of prevention and care are

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Figure 2.8: Prevention and care

3. Method

In this section a description of the used method is provided.

To reach common ground between the disciplines involved, an integrated research question has been formulated. A literature review on the topic was performed by each individual discipline (Groet, 2013, Van Mens, 2013, Savenije, 2013). The integrating technique of organization was used to interrelate the different aspects and theories found in the individual literature reviews. This organization is achieved through the public health model in the previous section. That model shows how the various domains involved in the problem interact and are causally related (Repko, 2012, pp. 346-347). Furthermore, it is used as a theoretical framework to structure the results. An integrated solution is presented that goes beyond the single disciplinary

perspectives, based on effective and accessible strategies that have been found in the literature to resolve the public health burden of the rural poor in Bangladesh. (Tromp, 2013)

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Figure 3.1: Research integration (Tromp, 2013)

4. Results

In this section the results are presented, first for policy, then external developments and prevention and care.

4.1 Policy

Figure 4.1: Policy (RIVM, 2013)

Policy plays a central role in large scale health issues. The effectiveness is largely dependent on the quality of the government present. The Bangladesh Ministry of Health and Family Welfare (MHFW) develops ‘education materials, treatment protocols, training of health professionals, and patients’ identification’ (Rammelt, p. 23), however, there is little capacity to act at the local level. The American think-tank Fund for Peace currently considers Bangladesh a failed state (Fund For Peace, 2012). This generally implies that the Bangladeshi government is not capable of playing a strong role in the solution of the arsenic contamination problem. This excludes a short term solution strategy that has a strong top-down perspective. On the long term, however,

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the state is a necessary factor in order to guarantee the sustainability of solutions. Furthermore it should be noted that the ‘failed state’ is a controversial concept . ‘The failed state concept has helped identify and emphasise genuine problems. The concept has drawn overdue attention to the importance of state institutions in peace processes, in development efforts, and in

considering sources of transnational insecurity [...] yet imprecise concepts make for poor scholarship and bad policy. I have provided a critique of the fallacy of the failed state. The concept’s harm is not limited to extreme or isolated examples. The term is inadequate, even misleading, for virtually every country it purports to describe.’ (Call, 2008)

Community-based organizations (CBOs) or institutions that also address other issues than drinking water have evolved from the use of deep tube-wells. Contrary to historical initiatives by Western countries to aid in the development of poor countries, the intention of community based organizations is not paternalistic, but rather aimed at building on local organizations and

strengths (Davis, 1993). In order to increase governmental effectiveness, government officials should work with local existing CBOs. Furthermore, research shows that ownership through community-based enterprises can be part of a solution strategy, especially with regard to embedding the solution in local systems and hierarchies (Peredo et al., 2006)

One of the possible solution strategies could be to (re)design an organization that is embedded in local culture. Making the community commercially responsible has been a tried and

successful solution to environmental problems concerning community assets in developing countries (Dupuis & de Bruin, 2003). Especially since there have been problems with regard to ownership and the accompanying responsibility. Drinking water is a problem in many

underdeveloped countries, and a classic example of a public good that requires tailor-made organizations to take care of this resource (WHO, 1997). It should be noted that community-based organizations are inherently slow to build. They usually form out of existing structures, making it very complex to change them. Changing the status quo of the social structure involves

4.2 External developments

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The presence of high levels of arsenic in groundwater is situated in the Bengal Delta Plain, covering parts in Bangladesh. The arsenic is a sediment of the delta and occurs naturally in groundwater (Singh, 2006). Because of the program of UNICEF and the World Bank (Howard, 2003) the tubewells pump up the arsenic contaminated groundwater, consumed by the local communities. This can be indicated as an geographical external development in the model. As explained in the introduction, technical solutions to arsenic removal from drinking water exist. This could be done by simple filters in the long term and deeper tubewells in the short term (Rammelt et al, 2011). This could be indicated as technological external development. This can be assigned as an external economic development. Thus demographically, the rural poor are affected most significantly by arsenic contamination of drinking water (Howard, 2003). When someone encounters the effects of arsenic contamination, this will have a negative impact on their socio-economic status. The concept poverty is relevant for the results since 40% of the Bangladesh population lives below the poverty line, observing the rural population 43.80% lives below the poverty line (Bangladesh bureau of statistics, 2005).

Socioeconomic differences in health outcomes that are found in Bangladesh could be

understood through the theory about socioeconomic health differences (Mackenbach, 2008). The poor are more susceptible to arsenic poisoning, due to malnutrition and low health status. Arsenicosis also worsens poverty, because the diseases can result in disability to work, social stigma and discrimination. (Rammelt, 2011) In survey data analysis of Yang, Bain, Bartam, Gundrey, Pedley & Wright (2012), however, no significant relation was found between socioeconomic status and arsenic poisoning of household using tubewells in Bangladesh, although their measure might underestimate the inequalities (Hassan, 2005). Inequality is strongly present in Bangladesh, in all different forms, such as gender inequality, class inequality, education inequality and inequality in health (Subrahmanian, 2005). External social cultural developments can be indicated as traditional notions of communities. Due to the lack of education, arsenic poisoning as a medical health hazard proposed as a contagious disease (Hassan et al, 2005). A person with visible effects of arsenic contamination is socially excluded from the community and lives in a social and economic isolement. Affected people will

eventually contact the local leader in the community for financially and moral support. Community members have different experiences with local leaders and their knowledge (Hassan et al., 2005).

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4.3 Prevention and care

Figure 4.3: Prevention and care (RIVM, 2013)

Because the government is not able to tackle this issue local organisations have tried to provide clean drinking water technology (health protection) and treatment (care and cure) for the local population. However, most organizations fail to address the multiple issues involved. The local population sometimes is only provided clean water, but not treated, or vice versa. Furthermore, the population might become dependent upon external funding and resources. (Rammelt, 2011)

Maity (2013) found levels of iron and magnesium that are higher than WHO guidelines in Bangladesh groundwater; thus strategies that address the supply of safe drinking water also have to consider other pollutants than arsenic only. Despite efforts to mitigate arsenic exposure, the levels found by Gardner, Hamadani, Grandér, Tofail, Nermell & Palm (2011) in a longitudinal study remain highly elevated. Many wells have not even been tested for over six years (George, Graziano, Mey & van Geen, 2012). Thus monitoring and evaluation of surveillance of water quality (Howard, 2013) is necessary.

People generally are informed about arsenic presence in water sources, but the implications for health are understood less. The community lacks understanding ‘of the origin and health

impacts of arsenic.’ (Rammelt, 2011) Hygiene education is lacking in Bangladesh, while it is necessary for safe water use (Howard, 2003). Sarker (2012) found that literacy ‘rate, daily wage rate of agricultural labor, arsenic status, and percentage of red mark tube well usage in districts contribute positively and significantly to households’ knowledge’ (Ibid., p. 1232) However, financially, a significant part of the population cannot afford or is not willing to pay for clean drinking water technology (Ahmad, 2003)

The medical treatment of arsenic poisoning has not been developed fully. (Howard, 2003) However, chelation (binding arsenic) with dimercaptosuccinic acid (DMSA) or

demercaptopropanesulfonic acid (DMPS) is recommended to reduce the toxic effect of the arsenicals (UpToDate, 2013). It is unclear whether this can be feasible treatment option in

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Bangladesh. The accessibility of arsenic-related diseases diagnosis and treatment is

inadequate, however, especially for the poor. The poor cannot afford consultations, medicine, surgery against carcinoma, or even transportation to health centers, for example. Patient commitment to treatment is low, especially after symptoms are relieved while treatment is necessary over an extended period of time. In Bangladesh, currently, treatment by the AMRF ‘consists of anti-oxidants (vitamin A, C and E), folic acid, anti-histamines against itching and salicytes to treat skin lesions.’ The development of household vegetable gardens by patients is stimulated to reduce the toxic effect. (Rammelt, Masud, Boes & Masud, 2011)

Medical registries are necessary to gain insight into the arsenic poisoning of the population of Bangladesh and to monitor the quality of treatment (Glicklich & Dreyer, 2011). The proportion of the population that is exposed and will develop arsenic poisoning is uncertain (Howard, 2003). Despite efforts to mitigate arsenic exposure, the levels of arsenic in drinking water found by Gardner, Hamadani, Grandér, Tofail, Nermell & Palm (2011) in a longitudinal study remain highly elevated. Many wells have not been tested for over six years (George, Graziano, Mey & van Geen, 2012). Thus monitoring and evaluation of diseases and the surveillance of water quality (Howard, 2013) are needed.

5. Discussion

In this section we will summarize the main findings and discuss strong and weak points of the research.

The Bangladesh government does not have sufficient control over the population to enforce effective policies at the local level. NGOs have sometimes failed to provide solutions, because of their monodisciplinary approach. Local initiatives and integrated approaches seem more promising. Community based organizations are an example of an integrated solution. Although these organizations are key to the solution, it may be very difficult to change them. This change is needed to improve their effectiveness further.The community based organizations require controlling and monitoring. An independent organ is needed for the controlling, monitoring and optional intervention. It is unclear which organ could be sufficient to execute this task. Although technical solutions are available to provide safe drinking water and quality health care, the rural poor population cannot financially afford improved sanitary technologies or medical treatment by itself. Therefore support from external organisations is necessary to address acute needs of the population and help them to become more independent and assertive to stand up for their own needs. In the long run, governmental reform is necessary, thus the local population and

organisations have to try to share their experience and lobby at the Bangladesh government to develop effective and sustainable policies.

This research has integrated various aspects involved in the issue of arsenic poisoning of the population of Bangladesh. This way, shortcomings of former monodisciplinary approaches that were insufficient to deal with the complexity of the problem have been overcome. However, this study was limited in time and resources. Therefore, it was mainly based on a literature review and it was not possible to study the problem in Bangladesh in a fieldwork research study. The results and proposed solution strategies are therefore limited. Scholars and development

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organisations in the area could, however, use the applied framework to assess whether current approaches are sufficiently comprehensive and where improvements or opportunities could be found. This report consist of an interdisciplinary approach of three disciplines. However, these disciplines do not cover all the domains related to this complex problem. More disciplines could be included into the research to compose a complete overview. This includes the disciplines earth science and politicology. Furthermore, different stakeholders could use our approach to find common ground to design a solution together.

6. Conclusion and recommendations

In this paragraph we will propose our main conclusion and recommendations.

“What solution strategies to resolve the arsenic-related public health burden will fit the needs of the rural poor population in Bangladesh in terms of their health condition, and will fit their social, economic and physical constraints enforced by their environment?”

Because neither the government of Bangladesh nor the rural poor population that is affected mostly by the problem can resolve the issue by itself, providing direct relief in the form of water supply and medical treatment to victims by external agencies is necessary in the short term. This should be combined with educating and organising the local population to hand over and maintain the technical and organizational solutions in the medium term. Education programs inform the local communities and leaders, which will defeat the social stigma and poverty. This approach should be aimed explicitly at improving the health condition and resilience of the local population to cope with physical, mental and social stress. In the long run, governmental reforms are necessary to provide the rural poor sufficient resources and education to be able to maintain access to clean water sources, gain job opportunities that raise their standard of living and to afford basic health care. Furthermore, it has been shown that a public health approach can be used to comprehensively address the arsenic-related public health burden in Bangladesh.

Further research should assess concrete approaches of local initiatives in Bangladesh to

determine shortcomings and opportunities for improvement, using the approach outlined above. Monitoring of water quality and registries of the public health burden are necessary to

benchmark best practices and evaluate progress towards eliminating the problem.

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Attachments

A. Data Management Table

Discipline or subdiscipline

Name Theory + Insights it gives into Problem

Key Concepts Underlying assumptions (ontological (o), epistemological (e), methodological (m), general (g))

Human Geography: Theory of the neutral state

a neutral state is a supplier and a

protector for its nation Medical Informatics:

Epidemiology

Determinants of Health

o) there exist various determinants of health and explicitly not merely health care e) to understand health outcomes, these various determinants have to be known and interrelated Business Studies: Health Economics Community Based Organization Willingness to pay, willing to accept, ability to pay, entrepreneurial Public resources require management (g), entrepreneurial thinking improves

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thinking performance of management of resources (o),

Consumer willingness to pay can be

measured (e), every good or service has a price that can be expressed in financial units (o),

Arsenic poisoning of rural poor Bangladesh