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Impact of High Incidence ofKidney Stone

A Study of Coastal Villages in Junagadh, Gujarat

Rajnarayan Indu and Alka Rawal

research studies AUGUST 2007

A K R S P - I

AKRSP(I) a profile

P R O G R A M M E A R E A S O F A K R S P ( I N D I A )

Bharuch, Surat and Narmada districts are some of the poorest areas in the state of Gujarat. A very

poor tribal community live on undulating and degraded land that was once heavily forested.

Junagadh district on coastal Kathiawar Peninsula faces a problem of salinity due to overexploitation

of groundwater. Natural resource are either degraded (like the dry Meghal River) or out of bounds

for the tribals and other disadvantaged people (such as around the Gir Protected Area).

Surendranagar district is one of the most drought-prone districts of Gujarat. Most villages in this

district face an acute shortage of water.

In MP, AKRSP(I) has begun work in Khandwa and Burhanpur districts which are home to marginalized

tribal populations who live in poverty despite the rich natural resources base.

Kutch district is extremely drought prone, AKRSP (India) provides training to organisations coping

with drought in the district. It works in collaboration with other AKDN agencies to drought proof

several villages.


Impact of High Incidence of Kidney StoneA Study of Coastal Villages in Junagadh, Gujarat

Rajnarayan Indu and Alka Rawal

Aga Khan Rural Support Programme (India)


FOREWORD

The study �Impact of high incidence of kidney stone: A case of coastal villages inJunagadh, Gujarat� by Rajnarayan Indu1 of the International Water ManagementInstitute (IWMI) TATA programme and Ms. Alka Rawal2 of Aga Khan RuralSupport Programme (India) AKRSP(India) provides an insight into the healthimpact of coastal salinity ingress. Research in coastal salinity has largely focussedon the technical issues (hydrogeology etc.) or economic dimensions (decline inagricultural productivity etc.). There have been few studies focussing on the impactof saline water on the health of the communities. This study is therefore valuableas it shows how an environmental issue affects the health and how these healthproblems affect the livelihoods of the affected households.

With increasing salinity and water scarcity problems throughout the 6500 kmcoastline of India, it is obvious that more studies needs to be done throughout thecoastline.

I hope this study will be of use to all those who work on the coastal ingress of thecountry, including health professional and state health authorities.

Apoorva OzaChief Executive Officer

1 IWMI-Tata Water Policy Programme, Vallabh Vidyanagar, Gujarat, e-mail: [email protected]

2 Aga Khan Rural Support Programme (India), Ahmedabad, Gujarat, e-mail: [email protected]

The authors are sincerely thankful to Dr Sunderrajan Krishnan and Mr Nirmalya Choudhury forstatistical analysis in this paper.


1. Introduction: Salinity Ingressin Mangrol, Junagadh

Gujarat has the longest coastline of 1600 kmsamongst all Indian states. Along this coastlinethere are about thousand villages in Saurashtraarea. The groundwater available in this coastlinehas more than 2000 ppm of TDS throughout theyear due to seawater intrusion and excessivegroundwater extraction. In the High LevelCommittee Report of 1977 it is said that 120villages of Junagadh district were affected by highsalinity. It has also reported that more than 2.8lakh people and about one-lakh hectares ofcultivable land in Junagadh were affected. Theextent of salinity ingress was found from 2.5 to7.5 kms inside the coastline (High LevelCommittee Report (HLC -1), 1978, 17). In arecent study undertaken by IWMI-Tata WaterPolicy Programme, it was found that the salinityingress increased up to 12.5 kms with an averageof 8.25 kms inside the land from the seashoreduring the last three decades in Junagadh district(Raychoudhury and Krishnan, 2006). This hasaffected more than 1 lakh 30 thousand hectares(about 15%) of the total area of the district. The

Aga Khan Rural Support Programme (India)working for the last fourteen years in Mangroltaluka of Junagadh has recognised 25 of 65villages as fully saline in 2006. The salinityprogramme of AKRSP(I) is operational in 65villages in Mangrol, Veraval, Maliya and Keshodblocks of Junagadh district.

The problem of salinity in the coastal region hascreated a very adverse condition in respect ofdrinking water supply and other aspects in thelives of the people. The spread of salinity hascaused social hardships and several negativeexternalities such as decrease in farm production,shifting of labour from agriculture, health impactsand later non-sustainability of secondary andtertiary sectors.

Individual researchers have put much effort tostudy the physical problems of salinity andGovernment also has put its effort to the salinityproblems by appointing High Level Commission,and Khar Land Development Board. Institute likeCentral Salt and Marine Chemicals ResearchInstitute at Bhavnagar is also engaged in thisendeavour. However their main focus was on the

Impact of High Incidence of Kidney Stone2

genesis of salinity problems. Moreover, the effortswere also made at different times either to studythe specific salinity condition or to makeassessment of some segments of the coastalregion. Hardly any documentation foundregarding the impact of salinity on human healthand the socio-economic aspects of the people incoastal region. The impact assessment of coastalsalinity on the livelihoods of the people andcoping strategies may provide proper perspectivewhich might be useful to formulate an efficientmanagement plan to bear with the menace ofsalinity on health in coastal region.

Seawater intrusion has changed the groundwaterquality in Junagadh contaminating with excesssalinity with very high Total Dissolved Solids(TDS). The presence of limestone in the seashorecauses high Calcium in water particularly inJunagadh coast. Consumption and irrigationwith this poor quality water can cause variety ofsuffering towards human and cattle health andalso can reduce the crop output.

The high sodium in seawater ingress may causehypertension too. There are typical kinds of skindiseases found among the people who areexposed to high salinity water for a long time.Most significant health hazard in the salinityingress area is kidney stone, which generallytakes place due to high calcium, and magnesiumavailable in saline water besides other reasons.Urologists of Junagadh estimate about 6% of thepopulation in the district are suffering fromkidney stones. Five years ago there was nourologist practicing in Junagadh, now there aretwo private practitioners in the city and a fewmore in other hospitals. Medical practitioners saythat etiology of ailments such as hypertension,skin diseases and kidney stone include manyaspects other than only salinity. Therefore it isnot always easy to establish salinity as the onlycause for all these three ailments. However,

though there are other environmental and socialreasons like extreme climate, less rainfall, moreperspiration and life style of the people and foodhabits, local doctors strongly opined that one ofthe most important reasons for kidney stone inJunagadh is the presence of high amount of TDSand calcium in the water used for consumption.

1.1 Possible reasons of kidney stonesin Junagadh:

As said earlier intrusion of seawater increasesTDS in groundwater to more than 2000 ppm, andpresence of lime stone in the seashore causes highcalcium beyond acceptable limit of 45 mg/l inJunagadh coast. People largely use groundwaterfor drinking and cooking in this area. Doctorssay that the high TDS and high calcium contentsin the drinking water is the major cause of kidneystone in Junagadh, besides other reasons like �extreme climate, sweating, food habits and intakeof lime with paan masala etc.

A popular urologist Dr Shyam Sonayia inJunagadh town did some chemical analysis of thestones he took out after operation.

We got a report of chemical analysis of 119 stonesfrom him; 106 (88%) of those stones werecontaining 2 to 3 degree of calcium-oxalate.Looking to the report said the same urologist thatthe high content of calcium and excess TDS inthe water is the foremost cause of kidney stonein this area. Of these 119 stones 79% were frommale and the rest from female patients. It is saidin medical journals that men are more vulnerabletowards kidney stone than women. Dr Sonaiyahad 115 Lithotripsy (an ultrasonic procedure ofbreaking kidney stones called Lithotripsy) casesin one year from November 2005 to November2006; that is he got about 10 patients in a monthfor Lithotripsy only! Besides these there wereother surgical and medical cases of kidney stonealso in the same clinic. This report is only from


one urologist of Junagadh city. One can imaginethe scenario if all the reports are available fromall urologists and urology departments in thisdistrict!

The health hazards due to environmental reasonsamong the people of a region can have impacton the total development of that region, because�good health is one of the most precious assets ofany population, but it is particularly importantfor populations that are poor and vulnerable.�(Woodward, Alistair et al, 2000). Woodwardnoted further that �when �bread-winners� suffersserious ill health or injury, entire households cansuffer, not only because of loss of income but alsoas a consequence of the high direct cost of medicalcare, a common cause of impoverishment initself�. Thus the weak health of human resourcewill be a serious hurdle for the development of aregion. The occurrence of significant number ofcases of kidney stone in this region due to waterquality in general, calls for investigation aboutthe socio-economic aspects of the afflicted families.We like to recall here about �Fluorosis� and�Arenicosis� which are also caused by poorwater quality containing high amount of Fluorideand Arsenic. This also has very negative effecton the development of the affected region (Shahand Indu, 2002 and Indu, et all, 2006). Hencethe quality of water plays a very important roleon health of the people in a region.

2. Research Objectives andMethodology

The study, therefore, tried to focus on the socialimpact of high salinity, particularly on expenseson medical care for the incidence of kidney stonesin the populace. Focus was to understand the (i)prevalence of the kidney stone, (ii) medicalexpenses for it, (iii) loss in wages due to inabilityto work and (iv) expenses on good quality water.Understanding that cases of hypertension and

skin diseases requires a long-time history ofpatients and can be attributed to several othercauses we did not focus on those health ailments.Therefore our objectives are as follows:

2.1 Objectives

1. To estimate the prevalence of the kidney stoneailments

2. Expenses on medical treatment for kidneystone

3. Loss in wages due to inability to work for theoccurrence of kidney stone, and

4. Expenses on good quality water to avoid thevulnerability of health

2.2 Methodology

Step1: A census survey was conducted in 5 studyvillages from the salinity affected (SA) villages inMangrol taluka and 2 control villages from thenon-salinity affected (NSA) villages in Maliyataluka, where AKRSP(I) has intervention forestimating the prevalence of kidney stone casesusing five most important symptoms based onthe discussion with consulting urologists. Astructured questionnaire has been used as toolsthat includes basic details of each member of ahousehold such as name, sex, age, education,years or stay in village along with 5 mostimportant leading symptoms of kidney stone andexpenses on water.

Step 2: Since there is no benchmark data for thisstudy, we selected villages from the area whereAKRSP(I) has intervention since the last ten yearsor more. They are working in 40 of 65 villages ofMangrol taluka. The study villages were selectedfrom Mangrol taluka on the basis of high salinityusing database of AKRSP(I) and control villagesfrom Maliya taluka on the basis of no-salinity.Village-wise water quality database of past yearsfrom AKRSP(I) records has been scrutinized forjudicious selection of SA and NSA villages.


Step 3: Taking into account the prevalence ofkidney stone cases from the census data weselected a sample of 156 households with 176afflicted persons for a detail study from bothstudy and control villages. Here also we haveused a structured questionnaire for collectingfamily details of the afflicted persons, details ofmedical expenses, wage loss of the patient dueto inability to work for his ailment and expenseson potable water, and other infrastructure of thehouse etc. The medical expenses include:expenses on medicine (pre and post operation orany other), operation fees, hospital stay, transportto hospital from village and return and expenseson the person/s who accompanied the patientin the hospital.

Step 4: Twenty-five afflicted persons � 20 fromsaline villages, and 5 from non-saline villageswere selected from the sample households of boththe areas for pathological and other clinical testsby a professional urologist. They had regularblood, urine test, x-ray and ultra-sonography testsfor diagnosis of kidney stones.

3. A Profile of Study Location:

The Junagadh district has a population of24,48,173 (District Census 2001) among 4,32,884households. The rural population is 70.9% of thetotal population. Mangrol taluka has 70.2% ruralpopulation of the total 1,89,053. Maliya talukahas 85.4% rural population of the total 1,44,975population. The district has annual rainfallbetween 800 to 1000 mm and the temperaturevaries from 5 to 46 degree Celsius.

The five study villages of Mangrol are:Husseinabad, Sheriayaz, Shil, Talodra andZariyavada. The households (in parentheses) andthe population respectively of these villagesaccording to 2001 census are: Husseinabad (358)2745, Sheriayaz (578) 4247, Shil (1206) 6539,Talodra (255) 1506 and Zariyavada (377) 2195.

These SA villages are situated between 0 to 9 kmsfrom the seashore (see Map). For example, Shil isright on shore i.e. 0 km. and Zariyavada is atabout 9 km from the seashore.

The two control NSA villages are from Maliyanamely, Ambalgadh and Tarsingra. Thehouseholds (in parentheses) and population ofthese two villages are according to 2001 census:Ambalgadh (243) 1238 and Tarsingra (226) 1206.Ambalgadh is located about 25 kms andTarshingda is about 28 km away from seashore.

3.1 Profile of SA villages in Mangrol

The coastal belt from Prachi to Mangrol ofJunagadh has long been famous as �Lilly Nagher�because of the luxuriant growth of vegetables,fruit gardens and other high value crops. Groundwater has been the main source of irrigation inthis area. There are no surface water reservoirsexcept few tanks and check-dams. Withadvances in agricultural techniques peopleswitched over from conventional techniques oflifting water with Mhot, to pumping sets. Theelectrification of rural areas gave further impetusto pumping of ground water with the help ofelectric motors. �The amount of water lifted fromthe coastal aquifers between any two monsoonsincreased over 10-15 times� (Shah, 1993, 154). Asthe water levels fell, the wells were deepened inorder to get increase supply of water or tocontinue getting the same quantum of yields. �Athird of Husseinabad�s wells located on fieldscloser to sea became saline. � all water pumpfrom these wells now is unfit for irrigation� (Shah,1993, 166). The crop yield was affected. Price ofCoconut fell down to half or more than half asthe size of the fruit shrunk. Also, the yield ofcoconut dropped to about one third. Easyavailability of institutional finance for pump setsand electric motors facilitated the process ofinstalling large number of wells enhancedwithdrawal of groundwater at a phenomenal


pace in the area leading to lowering down thewater table and more intrusion of seawater. Thiswas not accompanied by corresponding rechargefacilities. Thus this process worsened rapidlydeterioration of groundwater quality in thecoastal area of Junagadh. In addition, the tidalwater, which travels upstream along riverchannels, has not only contaminated surfacewater but also affected the quality ofgroundwater due to percolation. As a result,many families migrated to sweet water area andsettled3.

The geological formation of all the chosen fivevillages is from Gaj bed, which has highly porouslimestone. The excessive groundwater extractionhelped water table deepened and made watersaline for its simple geographical reasons. Thedigging of wells has been decreased recently butnot stopped as this area has been declared asunder dark zone. Now in this zone subsidies arenot available for digging a well. Still then almost25 new wells are dug every year in Shil! Currentlythere would be around 800 wells approximatelywith around total 600 landholders in Shil. Same

scenario exists in Talodra, Zariyavada andSheriyaz. The employment opportunity is as lowas only 90 days even in a good monsoon year inthese SA villages. Due to increase in familyfragmentation, the land is divided to small piecesand the current land holding is so small that itdoes not support the households. More than 50%of households have below 2 hectares of land.Many members of the coastal farmingcommunity from Mangrol are adopting diamondpolishing in Bhavnagar district as a prominentalternative occupation. It is observed that at leastone member has migrated to Bhavnagar fordiamond cutting work from about 30 per cent ofthe families of Shil village. Many of them havegone to Junagadh town in search of alternativeemployment. Many landowners of theses villageswith severe seawater intrusion have becomeagricultural labourers. They look for agri-labourwork on daily basis in neighbouring sweet watervillages. Almost 3000 men and women fromSheriyaz have migrated to a nearby Antrolivillage, which is still not affected by saline waterduring the last few years.

3 Mr Ranabhai Vajashi of Chakhoa village (not selected) said that 30 years ago there were 30 to 35 wells in the village whenwater was available at 33 feet and now the number of wells has exceed to 109 and the water is available at 72 feet below theground. About 30 families have left the village in 2003 due to high saline water in their wells.


From all the five saline villages the better-offcommunities such as Patels have migrated fromsaline zones long back. Communities like Patels,Lohanas and Kshatriyas have bought land inthose non-saline affected villages, and eventuallythey are settling there. Today the population inthese coastal villages largely consists of Ahirs,Kolis, Vagharis, Rabaris and Dalits � the peoplefrom lower rung of the society. Eventually thisalso has impact on total development of an area.At the end along with farm pattern, the socialstructure of villages changed due to prolongsalinity. This has changed the economic activitiesand people�s livelihood too.

3.2 Profile of NSA villages in Maliya

Ambalgadh and Tarsingra are comparativelyprosperous villages. The population largelyconsists of Patels, Ismailis, Rajputs, Rabaris,Dalits, etc. The geology is of basalt; hence watercan be recharged and salinity would be reducedperiodically. Meghal River is flowing throughthese villages and there are dykes, which are goodfor recharging groundwater. The people in thesevillages have used this potential to harness morewater. There are few organizations, which areworking here for the benefit of communities sincemany years. The Ismaili Jamat has doneconsiderable work for health and education inthese villages. The education among girls andhigher education among the youths hasimproved due to the presence of the Ismaili Jamat.Here also water table has down 70 to 100 feetdue to excessive withdrawal of groundwater. Thewater table of Ambalgadh village has beenimproved since the completion of theChandravati dam in 1996. In general, the peoplehere are well-off compare to SA villages due tothe absence of salinity-hazards.

4. Census Survey – Prevalenceof Kidney Ailments

A census study was undertaken to appreciate theprevalence of kidney stone ailments in the above-mentioned selected seven villages. There are somedifferences found in the total number ofhouseholds and populations of these villagescompare to the Government of India censusreport of 2001. The reasons are obvious such assome households were not available during oursurvey, some families have been divided in toseveral numbers since 2001, some have migratedtemporarily or for a long time.

Based on discussion with several urologists, wehave selected most important primary symptomsfor kidney stones and asked in question form,which are as under:

1. Do you get pain from loin to groin?(Annexure � 1, Figure � 4)

2. Do you feel any burning when passing urine?3. Have you ever passed blood in your urine?4. Does urination stop in midstream for pain?5. Have you passed sand like granules with

urine?

Prevalence of kidney stone symptoms

All these five symptoms are the leading symptomsfor diagnosing kidney stones or urinary calculi.However, among these five symptoms, if a personhas both symptoms 1 and 5 then it would be muchsure that he/she is suffering from stone formationin kidney or anywhere in the urinary system.Urologists say � combination of symptoms 1 and 5leads to probable presences of kidney stone.

Kidney stone problem or the problem of urinarycalculi develops over a time depending on theperson�s metabolism, food habits, water intake,sweating, life style, climatic conditions aroundhim/her and other environmental factorsincluding water quality. The presence of more


number of symptoms does not lead to prove the�severity of the kidney stone� or the �severity ofsalinity impact� as urologists say. Even one or twosymptoms can be so severe that at times thepatient may have to go for immediate surgery orintensive medical care.

We have interviewed 2966 HHs (Households)that has 13,788 populations in five SA villages.The villages have differences in their progress andpoverty, however, the water quality criteriaremains more or less similar among these villages(Table 1). Average TDS in these villages was 3462and average calcium was 296, whereas in the twocontrol NSA villages the corresponding figuresare 346 and 52 respectively. Indian StandardInstitute (ISI) confirmed permissible TDS as 500mg/litre and Calcium as 75 mg/litre whereasWHO say that TDS should be nil and Calciumshould be 50 mg/litre for drinking water. Of thetotal population in the saline villages 7.9 % peoplehave at least one of the five symptoms of kidneystones (or urinary calculi) and 4.4 % people haveboth the symptoms 1 and 5. This means more

than 4 % people are suffering from calculiproblem in SA villages. A contrasting picture isfound in the controlled villages, where only 3%are having at least one of the five symptoms and1.9% people are having both the 1 and 5symptoms. These two facts almost certainly,indicate that people living in the SA villages aremore prone towards kidney stone problems.However, there are variations in prevalenceamong the SA villages (Table � 1).

Incidence of Kidney Stone found higher in SAvillages (4.4%) compare to NSA villages (1.9%)is extremely statistically significant according toChi-square test. The two-tailed P value is less than0.0001. By conventional criteria, this differenceis considered to be extremely statisticallysignificant.

It is found that only 2.9 % of the total populationor 37% (407 of 1094 afflicted persons) of the totalafflicted persons of the SA villages have takensome kind of medical care (Table � 1).

Table – 1: Prevalence of Kidney Stone Symptoms in SA and NSA Villages

SA Villages HHs Population % of afflicted % of afflicted % of Total Av Avpopulation of the population of Population TDS in Calciumtotal with at least the total with Obtain Village in1 of the sym of sym 1and 5 Medical Village

5 symptoms both Care

Husseinabad 323 2394 8.8 4.8 4.3 2067 241

Sheriyaz 596 3005 4.0 2.9 1.7 1568 186

Shil 1561 5255 8.9 4.5 2.6 2831 139

Talodra 275 1298 12.1 4.9 2.2 4182 428

Zariyavala 211 1836 7.7 5.6 4.8 4935 505

Total 2966 13788 1094 604 407 3462 296

% to Total Pop 100.0 7.9 4.4 2.9

NSA Villages

Ambalgadh 207 1113 4.6 3.2 1.4 518 78

Talshingada 195 945 1.5 0.6 0.4 448 62

Total 402 2158 65 42 20 346 52

% to Total Pop 100.0 3.0 1.9 0.9

Source: Field Data


Among the total population of 13788 in ourcensus there are 7239 males and 6549 females.Urologists say that men are more prone to kidneystone - in this census study 66% men havesymptoms 1 and 5 both, against 34% of women,who are suffering of the same combination. Wefound a few cases of juvenile kidney stone alsoin our census study (Mani Menon et all (2002).

4.2 Years of stay and affliction

There was an opinion that staying in a salinevillage for longer time one might be suffering fromkidney stone. So we checked with the years ofstay in village and affliction of symptoms amongthe total population of villages. In the Chart �1,about 60% people who have stayed for the last20 years in SA villages about 23% of them havereported for the most probable symptoms ofkidney stone as they have both 1 and 5 symptoms.This includes women who have come to the villageafter marriage from other villages; and thepersons who are there from their birth in thevillage. Worst is the case when people stay more

than 40 to 50 years in those SA villages. Thereare 6% population of the total in this time rangeand 23% of them are suffering from both 1 and 5symptoms. However 40 to 50 years of stay in thevillages means people of higher age group, so thekidney stone for them may be for other reasonsalso. However we do not have a very strongargument to establish specifically this relation oflonger stay and kidney stone. We can only put itas observed phenomenon in the field or reportedinformation by the people.

This is the prevalence of kidney stones scenarioin Mangrol and Maliya taluka. Our hypothesisof high prevalence of kidney stone among thepeople of SA villages in Mangrol has becomestatistically significant compare to the NSAvillages of Maliya taluka. We find it relevant totalk about the people who are more prone tosuffer from kidney stone in the SA villages thanthat of the people of NSA villages where usuallyprevalence is very low and people arecomparatively better off. Further we have very

Years of Stay and Affliction of Symptoms

29.2

30.1

17.9

10.2

5.9 6.710

.2

17.5 21

.6

19.2

14.2 17

.3

6.3

15.4

22.4

16.8

23.1

16.1

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1 to 10 11 to 20 21 to 30 31 to 40 41 t o 50 51 to 99

Years of Stay in Village

Per

cen

t

% of Population % 1 to 5 Sym Found % 1 + 5 Sym Found

Chart – 1: Years of Stay in SA Villages and Affliction of Symptoms

Source: Field Data


few numbers of representative cases of afflictedpersons from these NSA villages to comparebetween patients of SA and NSA villages.Therefore we have now focussed on the detailstudy of the afflicted persons of the SA villagesonly to understand their socio-economicsituations, medical expenses and wage loss etc.

However before going to the detail study, let usadd a few paragraphs regarding kidney andkidney stone. This may help us to understand thecomplexity of the kidney and its stone. [Interestedreader can see Annexure � 2 for more detailsregarding kidney stone.]

5. Kidneys and Kidney Stone

5.1 What are kidneys and how do they work?

The kidneys are vital organs that perform manyfunctions to keep our blood clean and chemicallybalanced. The kidneys are two bean-shapedorgans about the size of a fist. They are locatedat the bottom of the rib cage at the back of thebody, just above the waist, on either side of thevertebral column (Annexure � 1, Figure � 1). Akidney smaller than 9 cms on ultrasound isusually abnormal (Muljibhai Patel UrologyHospital, Nadiad, Gujarat). The kidneys aresophisticated reprocessing machines. Every day,our kidneys process about 200 quarts of blood tosift out about 2 quarts of waste products and extrawater. The waste and extra water become urine,which flows to our bladder through tubes calledureters. The wastes in our blood come from thenormal breakdown of active tissues and from thefood we eat. Our body uses the food for energyand self-repairs.

If our kidneys did not remove these wastes, thewastes would build up in the blood and damageour body. The actual filtering occurs in tiny unitsinside our kidneys called nephrons. Urine,produced by the nephrons, travels downwards

from the kidney through small tubes calledureters (Annexure � 1, Figure � 2) to collect inthe urinary bladder. Each kidney is made up ofmillions of tiny filtering units called nephrons(Annexure � 1, Figure � 3). From the bladder, theurine passes out of the body through the ureter.In the nephron, a glomerulus � which is a tinyblood vessel, or capillary�intertwines with a tinyurine-collecting tube called a tubule. Acomplicated chemical exchange takes place, aswaste materials and water leave our blood andenter our urinary system. At first, the tubulesreceive a combination of waste materials andchemicals that our body can still use. Our kidneysmeasure out chemicals like sodium, phosphorus,and potassium and release them back to the bloodto return to the body. In this way, our kidneysregulate the body�s level of these substances. Theright balance is necessary for life, but excess levelscan be harmful (NIH Publication No. 06-4241,November 2005). Its function is to filter blood inthe body and clear it from poisons. It is alsoresponsible for excreting the end products of thebody�s metabolism in the form of urine, which iseliminated from the body during urination (site:www. Cardiogenetics.org/glossary.asp).

5.2 Kidney stone and its causes

A kidney stone is a hard mass developed fromcrystals that separate from the urine and buildup on the inner surfaces of the kidney. Normally,urine contains chemicals that prevent or inhibitthe crystals from forming. These inhibitors do notseem to work for everyone; however, somepeople form stones than others. If the crystalsremain tiny enough, they will travel through theurinary tract and pass out of the body in the urinewithout being noticed. Kidney stones maycontain various combinations of chemicals. Themost common type of stone contains calcium incombination with either oxalate or phosphate.(http://kidney.niddk.nih.gov/kudiseases/pubs/


stonesadults/index.htm). Doctors also use termsthat describe the location of the stone in theurinary tract. For example, a ureteral stone (orureterolithiasis) is a kidney stone found in theureter. To keep things simple, however, the term�kidney stones� is used throughout in this text.

The first ever history of urinary stones haveafflicted humankind since antiquity. The earliestrecorded example of bladder and kidney stonesdetected in Egyptian mummies dated 2488 B.C.(Mani Menon et al, 2002, p. 2262). Till 1980surinary stones were a major health problem. Overthe decades, development in medical sciences andintroduction of endoscopic surgery, this majorhealth problem has changed only to aninconvenience. The procedure of surgery or thetreatment of kidney stone could not prevent themfrom the reoccurrence. Treating urinary lithiasisrequires good understanding of all aspects of itsetiology, good diagnosis, medical and surgicaltreatment.

Referring Mani Menon et al (2002), urinarylithiasis has a sex bias towards male and alsotowards age. They say that the majority of thepatient report at onset of diseases in their teens.They also say that about three adult males areafflicted for every one adult female � we alsofound in our census data mentioned above. Thisis because of high level of male hormone presentamong adult men. �Women excrete more citrateand have lower incidence of stone formation thanmen� (Parmar, 2004).

Epidemiology (the scientific study of the causes,distribution, and control of disease inpopulations) says that the presence of kidneystones (calculi) in the kidney (nephrolithiasis)varies according to the geographical area andsocio � economic conditions. Nephrolithiasis maybe associated with renal insufficiency. A studydone in Karachi showed that 3% of the

population had silent stones. All the stone bearerswere male and most of the silent stones occurredin the left kidney (Kiersten Brazier � 2001,National Kidney Foundation (www.kidney.org)).A study was done in the tribal population of Indiato find out the association between the Fluorideand urolithiasis in humans. The results showedthat fluoride might behave as a mild promoter ofurinary stone formation by the excretion ofinsoluble calcium fluoride, increasing the oxalateexcretion and mildly increasing the oxidativeburden. A seasonal variation is also seen, withhigh urinary calcium oxalate saturation in menduring summer and in women during earlywinter. Urologists in Junagadh district in Gujaratalso observed this. The peak age of kidney stonefound in men is 30 years and women with peakage between 35 and 55 years. Once a kidney stoneforms, there is a probability of 50% that a secondstone will form within five to seven years(Kiersten Brazier � (2001). This is also found inour Junagadh study.

Medical evaluation of kidney stone is a complextask. The causes of urinary calculi are multipleas told above. It is further difficult to identify onebasic cause for stone. A detail chemical cultureof the operated stones or the stone particlescollected from the lithotripsy (an ultrasonicprocedure of breaking kidney stones calledLithotripsy) can give an idea of the compositionof the stone. A large number samples testedchemically can help to establish some provencause for this ailment along with otherenvironmental details and human habits that canlead to prove whether this urinary calculi is dueto geographical reason or due to high TDS andhigh calcium content in the drinking water.However, if we go by the prevalence result above,which is highly significance statistically thatsaline area people are more prone towards kidneystone, then high salinity and calcium in drinking


water should be the leading cause for the kidneystone.

6. Medical Expenses and Wage Loss

6.1 Selecting Patients

We carefully selected patients from our censuslist after estimating the prevalence of symptoms1 and 5 both (we are referring the symptoms bynumbers given in section � 4 above) and a few ofthem are with combination of all symptoms, 1 to5. First we preferred to select from the cases withboth the symptoms (1 and 5) because thiscombination signifies a most probable presenceof kidney stones and then from the mix of othersymptoms taking prevalence in to account. Anumber of cases have been dropped, as thosecases were not having the symptoms concerningstone. Many people complained about symptomsduring census survey about their pains relatedto urinary stone understanding that they may getsome benefits from the government. Actuallysome of those complaints were of symptomsregarding pains of other reasons, like urinary tractinfection or enlargement of prostrate glands.Those cases were filtered keeping the focus of our

study. Thus we selected 156 households withkidney stone cases; this is a little more than 5%household of the total census households. Somehouseholds have two patients, so we have total176 patients with stone-related complaints. Thismeans that there is more than one patient in ahousehold. From the NSA villages we selected 7households, which is 1.7% of the total householdsin two NSA control villages and they have 7patients only. We are not taking these cases forour analysis henceforth, however we may referthese NSA cases at relevant context.

6.2 Selected Families of SA Villages

These 156 households have population of 1106with 584 men and 522 women in saline areavillages. The families were selected on the basisof afflicted persons and not on the basis ofeconomic status or social class. However, whilesurveying we found larger number of families ofSA villages is clustered in the lower monthlyincome groups. About 59% (Rs 500-3500) or 92families of total 156 from SA villages are betweenthe monthly income group of Rs 500 and Rs 3500(Chart � 2). The average monthly income per

Chart –2: Percent of Households from SA villages in Monthly Income Groups

Percent of Households in Monthly Income Groups

1.9 3.2

9.0 10

.3

22.4

12.2

7.7

7.7

5.1

5.1

3.8 5.1

2.6

0.6 3.

2

0.05.0

10.0

15.020.025.0

Less

than

500

500-

1000

1001

-150

0

1501

-200

0

2001

-250

0

2501

-300

0

3001

-350

0

3501

-400

0

4001

-450

0

4501

-500

0

5001

-550

0

5501

-600

0

6001

-800

0

8001

-100

00

1000

1-12

500

1250

1-15

000

Monthly Income Groups (Rs)

Per

cen

t

% of HHs in Sal Vill

Source: Field Data


household was Rs 3875 during the reference year(2006).

Among the five villages of Mangrol, thehouseholds of Shil village buy the least amountof water, because Shil has good number ofdrinking water wells than other villages of salinearea. The drinking water quality of these villagesis very much saline - TDS is more than 3000 mg/litre and the Calcium is nearly 300 mg/litre (Table� 1). The RRWH scheme started in 1995 in severaltalukas of Junagadh districts by different NGOslike AKRSP(I), Sarvodaya Trust and GWSSB. Itis found from the record of AKRSP(I) that inMangrol there are 2146 Tanks among 8434households of 26 villages covering 25.4% of thetotal households. Additionally there are RRWHbuilt by institutions other than AKRSP (I). Wehave come across that the SA village people aremainly from the lower rung of the social class asmany higher-class families have left for less salineor sweet water area, whenever they gotopportunities. More than 60% families of SAvillages are habituated of taking non-vegetarianfoods.

6.3 Medical Expenses forKidney Stone Ailments

It is fact that the stones in kidneys do not formovernight or by couple of months. However thereare exceptions. People do not visit doctors forinitial pains rather they take �grandmother�sremedy� initially. Pain does not occur at the initialstage especially if the stone is located inside thekidney. However if the stone is in the ureter � theduct carrying urine to the bladder, there will bepain signal in the area shown in Annexure � 1,Figure � 4, people go to visit doctors or Ayurvedsat this stage. The medical bills start from this stage.We have investigated these bills and collectedexpenses on pre-operative and post-operativeexpenses. The expenses includes � operation fees,hospital-stay fees, medicine expenses during

operation, pre and post operation medicineexpenses, transport expenses from village tohospital and expenses of stay for accompaniedperson/s and also their loss of wages, if any. Wehave collected these bills as much details aspossible from the patients irrespective of wherethey have been treated � either homeopaths,Ayurveds or allopathic doctors. Although themedicine costs do not vary much between twoshops, but the doctor�s fee, expenses in hospital-stay, fees for general surgical operations,Lithotripsy, x-ray and ultra-sonography do varyacross doctors, hospital and cities.

The operation expenses vary from Rs 8000 to Rs12000 even up to Rs 20,000 in a private hospitalor clinic in Junagadh, and it is less at Bhavnagarbecause the Bhavnagar hospital is run by acharitable trust. The operation fees varyaccording to the size and the location of the stonein the urinary system � whether it is inside thekidney or in the ureter or in the bladder. It isreported that expenses are much higher inAhmedabad and in Mumbai than that inJunagadh, but of course the expenses depend onthe kind of hospitals/clinic and the people go formedical care. In our survey, we have found anaverage total medical expense per person is Rs5790 in 2006 among the patients of SA villages,which includes accompanied person�s expenses,which is about 3% of the total cost. The averagemedical expenses are found nearly 14% of theirtotal income among all the population in salinevillages (Table � 2). Among the households ofsaline area it is observed that the per cent ofmedical expenses is higher in lower incomegroups than in the higher income groups. It isobvious as they cannot take care of their regularpreventive health care, so when they fall sick,they have to spend as much as they can affordfor their cure.


In the lower income group the per cent ofexpenses over income went up to 94%, this is theexpense in the year of treatment particularly inthe year when operation was performed. Themedical expense has inverse relation withincome. The local urologists say that 80% of thekidney stone cases are repetitive within 5 to 7years. Therefore the afflicted families particularlyfrom saline area may have to spend again and inthe future unless they take some preventiveaction like changing the water quality they drink,which may be the major cause for kidney stoneof this district. They need to keep or arrange forthe future medical expenses also.

6.4 Wage Loss for Kidney Stone Ailments

The average annual income per household insaline area families is Rs 46884 (Table � 2). Allthe afflicted people have not lost their wages, asmany of them were not earning members.Among 176 afflicted persons from saline area 97persons (55%) reported their loss in wages. Thusaverage wage loss per reported person in salinearea was found as Rs 2867, which shows thedepth of the impact of salinity on the livelihoodin SA villages (Table � 2). This wage loss is besidethe medical cost incurred. The average wage lossis about 50% per person of their current yearincome.

Table – 2: Income, Medical Expenses and Wage Loss

SA Villages No. of No. of Estimated Medical % of % of No. of WageMonthly HHs in Patients Annual Expenses Med Exp. Med Exp Person loss ofIncome Monthly in Monthly Income of of Monthly of Total to Total Reported ReportedGroups (Rs) Income Income Monthly Income Annual Income Wage Loss Persons

Group Group Income Group Income of of All acc. To in theGroup (Rs) (Rs) that monthly HHs Monthly year of

Income Income operationGroup Group (2006)

< 500 - - - - - - - -

501-1000 3 3 27000 25500 94.4 2.5 3 14250

1001-1500 5 5 75000 49000 65.3 4.8 3 8800

1501-2000 14 14 294000 71750 24.4 7.0 8 13550

2001-2500 16 19 432000 88500 20.5 8.7 7 37500

2501-3000 35 37 1155000 191750 16.6 18.8 22 65620

3001-3500 19 22 741000 78250 10.6 7.7 17 43500

3501-4000 12 14 540000 102750 19.0 10.1 7 11000

4001-4500 12 14 612000 79000 12.9 7.8 6 13950

4501-5000 8 8 456000 58000 12.7 5.7 5 7600

5001-5500 8 10 504000 74250 14.7 7.3 2 10700

5501-6000 6 8 414000 21200 5.1 2.1 7 32350

6001-8000 8 10 672000 42250 6.3 4.1 3 12700

8001-10000 4 5 432000 23000 5.3 2.3 3 3525

10001-12500 1 1 135000 6000 4.4 0.6 0 0

12501-25000 5 6 825000 108000 13.1 10.6 4 3100

Total 156 176 7314000 1019200 13.9 100.0 97 278145

Av. Per Person 5790.9 2867.5

% to Total 13.9 3.8

Per HHs 46884.6 6533.3 1783.0

Source: Field Data


7. Expenses on BuyingDrinking Water

In general, people use the village sources fordrinking water, either from Panchayat suppliedone or from irrigation wells nearby. The averageTDS found more than 3400 mg/litre and Calciumnearly 300 mg/litre mentioned above in Table �1. In SA villages, people buy water daily for about150 days in a year at the rate of Rs 5 to Rs 7 per35 litres of carboy. Its water quality isquestionable because the water is brought fromwells of nearby villages, where water iscomparatively less saline. In the report of the 25samples collected from the village sources � 5each from 5 SA villages, we found that the TDScontained it about 700 mg/litre and Calcium ismore than 60 mg/litre. This is the quality ofwater that they use regularly. The expense onthis drinking and cooking water is Rs 5/-(minimum), assuming the lower price of Rs 5/-we get Rs 750 per year per family for 5 monthsin a year. Families, who have underground tankwith a capacity of 10000 litres for harvestingrainwater, are also to buy one or two tank full ofwater towards the end of the year at the rate ofRs 250 to Rs 300 per tanker of 5000 to 7000 litresof water.

Thus social costs due to poor quality of high salinewater form a significant part of people�s income.Since the respondents have very low-incomebase, so any attack of kidney stone hit them hardin the short run. Therefore, the expenditure needsto be managed from either current income or fromexternal borrowing. The loss in wages alsoreduces their current income. Thus the formationof kidney stone put these people in distress. Theextent of this distress to these people can be ashigh as about 18% (13.9% medical expenses +3.8% wage loss, Table � 2) of their current annualincome. As kidney stone can recur after 3 to 5years hence inflicted persons should save someresource for future medical expenses.

A Few Remarks About NSA Villages

� The families of NSA villages have higher income.About 57% families of NSA villages were in theincome group between Rs 4501 and 8000.

� They do not have to face the environmentalhazard like high salinity in their village. Theyhave higher agricultural income also, as thesalinity has not spoilt it, as in the SA villages.

� The families from NSA villages do not have tobuy water from out side except in some droughtyears. They also have tanks for Roof Rain WaterHarvesting Systems (RRWHS). There are 426Tanks among 5440 households in 7 villages inMaliya taluka till 2006; the coverage is 7.8% ofthe total households. The people from non-salinearea do not spend on buying water

� Population in NSA villages comprises of manyupper social class families because migration hasnot taken place like in SA villages.

� The patients of non-saline villages could spendmore on their medical bills as they havecomparatively more income than in SA villages.

� The occurrence of kidney stone is very less, andwhen occurred they could take the best possiblemedical package.

� The wage loss found higher than that of SAvillages. This is possible as the general income ofnon-saline area is quite high and therefore thewage loss happened to be high.

8. Reports from an Urologist:Dr Shyam Sonaiya’s Report of25 Patients

As part of methodology (Step � 4) of this study,we selected 20 patients for clinical andpathological tests out of 176 patients with at leastone of the five symptoms from saline villages and5 non-patients from non-saline villages. These 25people, 18 men and 7 women were sent to a localurologist Dr Shyam Sonaiya, who has his ownprivate clinic at Junagadh city. The doctor hasarranged all the necessary blood, urine test and


also x-ray and ultra-sonography examination. Hiscertified report is as fallows:

�Total 25 patients were examined in the study. Outof them six (6) patients, who were from saline areavillages were suffering from stone. In this study normalperson (patients) are having a few urinary symptomsor pain. Those may be due to some other infection,which needs to be investigated. The incidence of stonedisease in study region of Saurastra and Kutch isvery high. There are many other reasons also, butone of the important reasons is high TDS level indrinking water.� Sd/- by Dr Shyam Sonaiya.

From the details of this information we found 19patients were from saline villages, of them 6persons were diagnosed of having kidney stones,which means 31.6 per cent occurrence of kidneystone. The size of the stone is varying from 5 mmto 17 mm. The range of age is from 8 years to 38years. Out of 6 stone cases, 4 were men and 2women; here also we found that men are moreprone to this ailment. Rest 13 from SA and 6 fromNSA villages of the total 25 persons were foundnormal, however a few of them have some otherurinary complaints as told in his report, whichneed further investigations. Following this reportone can understand the severity of the impact ofsaline water in the study location.

9. In Conclusion

1. Intrusion of saline water from sea hasincreased the salinity of groundwater. Peopleuse groundwater for drinking that has highTDS and high calcium particularly in salinityaffected villages.

2. Salinity affected villages have high incidenceof kidney stone compare to non-salinityaffected villages. The prevalence data explainsthis between Mangrol and Maliya talukas ofJunagadh district.

3. The people of Mangrol taluka in salinity-affected area are require buying potablewater for their daily use.

4. The families afflicted by kidney stone haveto incur high amount of medical expenses andthey also have to lose wages in the year thestone has to be removed.

5. Besides all these there are other impacts onsocial aspects. There is typical resistanceregarding marriages between the families ofSA and NSA villages. The resistance is notonly for poor quality water and afraid of�pathri� (kidney stone) but also for fetchingdrinking water from a long distance, whichgirls would like to stay away from. This socialimpact is difficult to quantify.

6. People of SA villages, those had opportunitymigrated from village and settled in sweetwater area. Those who could not migratestay in the village with hardship. Theydepend on farm and non-farm labour in andoutside their village.

7. If 604 persons (4.4%) of the population of SAvillages are to remove their stone in one yearthey have to spend @ Rs 5790 medical costper person, that is (Rs 5790 x 604) = Rs34,97,160 and if 55% of them are to losewages then they are to lose @ Rs 2867 (Rs2867x 332) = Rs 9,51,844 as wages. That isthese villages may lose Rs 44,49,004 say Rs45 lac in a single year. This is the impact ofhigh salinity in groundwater in Mangroltaluka of Junagadh. We feel people shouldbe aware of this.

8. The result of our step 4 above shows that 6of 19 patients from SA villages have kidneystone that is 32% people are suffering whenselected randomly. This shows the magnitudeof the affliction.


9. There are some opinions that system ofRRWHS is not a very proven system that moreand more people are acknowledging it. Thesystem is not always affordable for all as it isexpensive. Further the rainfall is not constantevery year, so many a time the RRWHS tank(�tanki�) is used only storing the purchasedwater.

Identifying the cost of high incidence of kidneystones due to high salinity and other impacts onsociety, the problem deserves to get immediateattention from concerned authorities before it getsfurther worse.

References

1. Curhan, Gary C, Walter C. Willett, Eric B. Rimm,and Meir J. Stampfer, (1993), A Prospective Study ofDietary Calcium and Other Nutrients and the Riskof Symptomatic Kidney Stones, The New EnglandJournal of Medicine, Volume 328:833-838, Number12, March 25, 1993

2. Curhan, Gary C., Walter C Willet, Frank E Speizer,Donna Spiegelman and Meir J Stampfer, (1997),Comparison of Dietary Calcium with SupplementalCalcium and Other Nutrients as Factors Affectingthe Risk for Kidney Stones in Women, Annals ofInternal Medicine, Volume 126 Issue 7, pp 497-504

3. District Census 2001, (2006), Jilla PanchayatKacheri, Statistic Department, Junagadh

4. Indu, Rajnarayan, Sunderrajan Krishnan andTushaar Shah, (2006), Impacts of GroundwaterContamination with Fluoride and Arsenic:Affliction Severity, Medical Cost and Wage Loss insome villages of India, IWMI-Tata Water PolicyProgramme, International Water ManagementInstitute, Anand, Gujarat, India (under publishing)

5. Kiersten Brazier � (2001) National KidneyFoundation (www.kidney.org)

6. Mani Menon, Bhalchondra G. Parulkar and GerogeW. Drach, (2002); Urinary Lithiasis: Etiology,Diagnosis and medical Management, Cambell�sUrology (chapter 91)

7. Muljibhai Patel Urology Hospital, Nadiad, Gujarat8. National Kidney Federation (UK) http://

www.kidney.org.uk9. NIH Publication No. 06-4241, (November 2005),

National Kidney and Urologic Diseases InformationClearinghouse, National Institute of Diabetes andDigestive and Kidney Diseases

10. Parmar, Malvinder S, (2004), Kidney Stones, fromBritish Medical Journal, Vol. 328, 12 June 2004, p1420-1424

11. Raychoudhury Trishikhi and SunderrajanKrishnan, (2006), Ingress of Saline Water in CoastalAquifers of Junagadh, Gujarat, IWMI-TataProgramme, Anand, (unpublished)

12. Report of the High Level Committee Report toExamine the Problems of Salinity Ingress alongCoastal Areas of Saurashtra, 1978, Public WorksDepartment, Sachivalaya, Ganghinagar, Gujarat

13. Shah, Tushaar, (1993), Groundwater Market andIrrigation Development: Political Economy andPractical Policy, Oxford University Press, Ch. 7, 154

14. Shah, Tushaar and Indu, Rajnarayan, (2002),FLUOROSIS in GUJARAT: A Disaster Ahead,IWMI-Tata Water Policy Programme, InternationalWater Management Institute, Anand, Gujarat, India(unpublished)

15. Site: www. Cardiogenetics.org/glossary.asp16. Site; http://kidney.niddk.nih.gov/kudiseases/

pubs/stonesadults/index.htm)17. U S DEPARTMENT OF HEALTH AND HUMAN

SERVICES, National Institutes of HealthWoodward, Alistair, Simon Hales, NavitalaiLitidamu, David Phillips and John Martin, (2000),Protecting Human Health in a Changing World:the Role of Social and Economic Development,Special Theme � Environment and Health, Bulletinof the World Health Organisation, pp 1148-55www.kidney.nih.gov

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Impact of High Incidence of Kidney StoneA Study of Coastal Villages in Junagadh, Gujarat

In about thousand villages in coastal Saurashtra (Gujarat) the TDS levels have risen beyond 2,000ppm (remains throughout the year) due to seawater intrusion and excessive groundwater extraction.They have been known as fully saline villages. In Junagadh district of Saurashtra, intrusion ofseawater has increased from 3 to 12 kms during the last three decades and more than 130 thousandhectares (about 15 percent) of the total area of Junagadh are affected by salinity. In 2006, Aga KhanRural Support Programme (India), working for the last fourteen years in Mangrol taluka of Junagadhdistrict, recognised 25 villages as fully saline of the total 65 villages.

Seawater intrusion has changed the water quality in Junagadh contaminating it with excess salinityand different elements such as chloride, calcium, magnesium and sodium. This has led to preva-lence of several health hazards in the region namely kidney stones, hypertension and skin diseases.Urologists of Junagadh estimate that about 6 percent of district population suffers from kidneystones. Medical practitioners say that etiology (the study of the causes of diseases) of ailments suchas hypertension, skin diseases and kidney stone include many aspects and not just increase insalinity. One of the major reasons for kidney stones, however, is the high concentration of calciumin drinking water. A report of chemical analysis of 119 kidney stones prepared by an urologist inJunagadh showed that 41 percent and 48 percent of those had calcium-oxalate of degree-3 anddegree-2 respectively, which explains the presence of excess calcium in the body. The same urologistreported to have attended 115 Lithotripsy (an ultrasonic procedure of breaking kidney stones) casesin the last year in addition to other general operative and medically cured cases of kidney stones.What needs to be noted is that this was an experience of a single urologist in Junagadh. A detailedcompilation of reports from the Govt Department of Urology and other clinics of Junagadh mayprovide a much more alarming picture. The study aims to estimate the prevalence of kidney stonesin the region and understand its varied socio-economic impacts - expenses incurred in treatment,expenses incurred in procuring good quality water and loss in wages due to inability to work.

Based on a discussion with some urologists, five leading symptoms were identified to estimate theprevalence of kidney stone in the five selected study villages of saline area of Mangrol taluka andtwo control villages from non-saline area of Maliya taluka. A census of these villages revealed that7.9 percent of the population in fully saline villages and 3.2 percent in non-saline villages had atleast one of the five symptoms. The combination of two key symptoms (signifying a probablepresence of Kidney stones) was found among 4.4 percent population of the saline villages and 2.0percent in the non-saline villages. The average amount of TDS and Calcium found in saline villageswas 2,462 mg/litre and 296 mg/litre respectively, far beyond the maximum permissible limitsprescribed by ISI (500 mg/litre for TDS and 75 mg/litre for Calcium). The corresponding figures innon-saline villages were 345 mg/litre and 52 mg/litre respectively. In the saline villages, the averagetreatment expense incurred by an affected person was Rs 5,790 and average wage loss was Rs 2,690in the year one has to remove the stone. Urologists say that about 80 percent of kidney stone caseshave a chance of recurrence, raising the expenses incurred on treatment even further. Given its highsocial costs, the problem of kidney stones, thus, deserves immediate attention from concernedauthorities.

Key Words: Salinity, Kidney Stone, Medical Expenses, Wage Loss and Drinking Water Expenses

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