The hidden health costs of climate change along India’s coasts.

Rising sea levels and more frequent storm surges are causing salt levels to rise in the Sundarbans. Women are bearing the brunt of the impacts.

Mousuni is a small island on the eastern coast of India. It lies within the world’s largest mangrove forest, the Sundarbans, situated in the delta formed by the confluence of three rivers, Ganga, Brahmaputra and Meghna, as they flow into the Bay of Bengal. Tourism websites describe Mousuni as a land of “virgin beaches and fisherman fables”. But for the 20,000 odd residents of the island, life is a lot less idyllic. They are grappling with an increasing crisis of sweet water, as sea-level rise coupled with increased cyclones turn rivers, ponds and other freshwater sources increasingly salty. The only sweet water available on the island is from tube wells, a type of well with a long tube drilled deep underground and operated through a hand pump. But tube wells are scarce, leaving residents dependent on saline water for their daily chores — they bathe in it , use it to cook food and wash clothes, and drink it. Some families have resorted to buying water from local treatment plants, but for the 40 percent of households in the region who fall below Indias poverty line, packaged water is either too expensive or reserved for children and the (male) head of the family so the high-salinity water is boiled and consumed.

Health effects from constant exposure to high saline water is widespread. Across the Sundarbans, people suffer from skin infections, acute respiratory infections, and gastric and diarrheal diseases. Women are disproportionately affected. As far back as 2011, one study estimated that the amount of salt consumed by women in certain parts of the Sundarbans was 2-8 percent higher than the levels considered safe by the World Health Organization and the Food and Agriculture Organization. A more recent report pegs it at 18 to 20 times.

As the primary caregivers of their families, women do all the cooking, washing and cleaning, which prolongs their exposure to saline river and pond water, and leaves them more vulnerable than men to chronic ailments such as arthritis, asthma and vision defects. Then there is the additional burden of growing gynecological problems.

“Irregular menstrual cycles, urinary tract infections (UTIs), vaginal infections, pelvic inflammatory disease, miscarriages and other sexual and reproductive health issues have become commonplace among women in this region, especially over the past two decades,” said Dr Shyamal Chakraborty of RG Kar Medical College and Hospital, Kolkata, who has conducted several health camps across the Sundarbans. As more freshwater sources turn salty, and as their level of salinity increases, the number of women with such ailments has also risen, he added.

Researchers link the rise in water salinity in the Sundarbans – and the associated health problems – to environmental factors such as tropical cyclones and storm surges (the abnormal rise in sea levels caused by strong winds during a cyclone). While this low-lying delta has always faced the brunt of cyclonic activity, climate change is now exacerbating the intensity and frequency of tropical cyclones. Warming oceans and rising sea levels have resulted in at least 15 high-intensity cyclones in Sundarbans in the last 25 years. With that, saltwater has reached more than 100 kilometers inland. Whereas in the past, the 10,200 square kilometers of mangrove forests protected the region from the harshest impact of cyclonic damage, their large-scale destruction has left the region’s 4.5 million residents with very little environmental safeguards. Following each cyclone, many villages remain underwater for months and even years. Even after flood waters subside, ditches and tidal creeks push saltwater further inland into streams and ponds. The rest makes its way into underground water reserves, from where it is sourced through borewells and tubewells for consumption.

Cyclone Aila in 2009 tore through embankments in the Subdarbans, flooding villages. Photo Courtesy Anil Gulati /Flickr

Excessive salt intake, associated with elevated blood pressure or hypertension, is particularly risky for pregnant women. Hypertension in pregnancy can lead to “increased rates of adverse maternal and fetal outcomes, both acute and long term, including impaired liver function, low platelet count, intrauterine growth retardation, preterm birth, and maternal and perinatal deaths”, according to the authors of the 2011 study. Women in coastal areas, especially those living within 20 kilometers of the sea and seven meters above sea level, are 1.3 times more likely to miscarry than women living in non-coastal areas.

Occupational factors also put women more at risk. While long fishing voyages are typically undertaken by men, women in the Sundarbans earn a livelihood by collecting crabs and shrimp or prawn seeds, known locally as meen. This involves standing five to six hours daily in waist-deep saline river water. Along with fisheries, rice cultivation and forestry have traditionally sustained more than a third of Sundarbans’ population. But as saltwater intrusion makes agriculture unviable and depletes freshwater fish, more women are being pushed into meen collection for longer hours. This increases their contact with saline water and heightens their risk of pelvic inflammatory disease, with symptoms such as excessive menstrual bleeding, burning sensation during urination and painful sexual intercourse.

Women in almost every home suffer from menstruation-related health problems, said health worker Revathi Mondal who works in the Goran Bose village of the Sundarbans. Associated with the Accredited Social Health Activists (ASHA), a trained community of female health activists in India, Mondal has been working in the village for over twenty years. With each passing year, she has seen the severity of these health concerns exacerbate, an outcome that she attributed to the increasing salinity of the water in its rivers and ponds. Without access to sanitary pads, most women rely on old cloth during their period, which they wash in saline water and reuse. This increases their risk of vaginal and uterine infections, and bacterial and fungal lesions, said Dhires Kumar Chowdhury, general physician and president of the non-profit Banchbo (which translates to I Want to Live). Without treatment, such infections can become chronic and spread to other parts of the body, he added.

But treatment is hard to come by. In many places, the nearest health center is hundreds of kilometers away, often requiring boat transportation to get there. Many health centers lack qualified public healthcare professionals, leaving patients dependent on untrained medical practitioners who operate without a license and private for-profit healthcare providers who demand exorbitant fees. Due to social stigma, women are reluctant to approach male doctors to discuss their sexual and reproductive health complaints, which stands in the way of them receiving treatment. The same stigma also makes them unwilling to share their menstrual health problems with female ASHA workers unless they become unbearable.

Women are also more likely to prioritize the health of their family over their own wellbeing. In a study based in Tamil Nadu, a southern Indian state with its coastline in the Bay of Bengal, and one that is also prone to tropical cyclones, women said that they did not seek medical treatment due to “lack of time to go to government hospitals, discrimination and negligence by hospital staff, and lack of money to access private medical services”. One 47-year-old fish vendor who is the main earning member of her household told the authors of the study that “ my family, I have to spend a lot of money on medicine. I also have regular pains in my neck, knees and back. My husband and son are ill. But I am tolerating my own health problems as I cannot afford the costs.”

Besides the long-term problems stemming from saltwater intrusion, women are also the worst affected in the immediate aftermath of cyclones, when water and sanitation infrastructure break down and remain unavailable for extended periods. According to a World Bank assessment of the long-term trend of cyclone landfalls between 1877 and 2016, the Sundarbans and northern Odisha (West Bengal’s neighboring state) were the highest impact zones. Even so, these areas remain under-equipped when it comes to cyclone shelters and post-disaster medical assistance. When shelters exist, they lack functioning toilets and clean water. In many cases, a single toilet is shared by hundreds of evacuees, leaving them vulnerable to communicable water-borne diseases. For women, the inability to maintain genital hygiene increases susceptibility to UTIs, genital tract infections, bacterial vaginosis, and uterine inflammation and ulcers, conditions that a recent Lancet study links to cervical cancer. These problems are more acute for menstruating women. With drinking water sources submerged, and with the burden of fetching drinking water resting solely on them, there are instances when women have to travel long distances through waist-high flood water to fetch water in the days following a cyclone.

In the absence of clean water and sanitation facilities during climate disasters, women line up outside medical centers in their aftermath, health workers and gynecologists say. “If on average around 20 women approach us in a week on normal days, the number is 10 times higher during cyclones and floods,” according to Mitali Shrivastava, a gynecologist in a community health center in Odisha’s Balasore district.

None of this is to say that victimhood is the defining condition of women in India’s coastal communities. Far from it. In many villages across the Indian Sundarbans, women are coming together to plant mangroves that can protect embankments against erosion during cyclones. Women are also at the forefront of spreading awareness about human trafficking in a region where thousands of women and girls go missing every year as repeated climate disasters push families into a downward spiral of poverty. After the devastating Cyclone Fani in May 2019, women from a fishing community in Odisha started a resilience fund that can be used to “take care of small expenses and activities linked to pressing needs that follow immediately after disasters”. In Tamil Nadu, following the 2004 tsunami, women from the Dalit (an oppressed caste) community kept up a decade-long agitation, demanding that the government move them from temporary shelters to the housing constructed for survivors.

These are only a few of ways in which women have been active agents of change, enabling their communities to safeguard the region’s ecology and biodiversity and rebuild their lives in the aftermath of a disaster. But as climate change and climate-related insecurities worsen to unprecedented levels, the health and livelihood-related repercussions will only worsen. And unless local governments and the international community take women’s perspectives into account in their climate adaptation, disaster preparedness policies and post-disaster responses, the burden of resilience they carry will become an increasingly heavy one to bear.

Cover Image: A woman cleaning fish using water from a tubewell_Photo Courtesy Yousuf Tushar Flickr(1).jpeg

The author would like to thank Professor Nitya Rao and Dr Avni Mishra for their input while writing this article

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