Medical Geology: An Emerging Discipline

Robert B. Finkelman1, Jose A. Centeno2, Olle Selinus3, Joy Jacqueline Pereira4

1
US Geological Survey, Reston, VA, USA
2
US Armed Forces Institute of Pathology, Washington, DC 20306-6000 USA
3
Geological Survey of Sweden, Uppsala, Sweden
4
Institute for Environment and Development (LESTARI), Universiti Kebangsaan
Malaysia, 43600, UKM Bangi, Selangor Darul Ehsan, MALAYSIA

INTRODUCTION

Emerging diseases can present the medical community with many difficult problems.
However, emerging disciplines may offer the medical community new opportunities to
address a range of health problems including emerging diseases. One such emerging
discipline is Medical Geology. Medical Geology is a rapidly growing discipline that has
the potential of helping the medical community in the Asia Pacific Region and elsewhere
to pursue a wide range of environmental health issues. In this article we provide an
overview of some of the health problems being addressed by practitioners of this
emerging discipline.

BACKGROUND

Silverman (1997) defined environmental health as the impact of environmental

degradation on human populations. Medical Geology can be considered as a compliment
of environmental health dealing with the impacts of geologic materials and processes
(that is, the natural environment) on animal and human health. Medical Geology attempts
to bring together geoscientists and medical/public health researchers to address health
problems caused by or exacerbated by geologic materials such as trace elements, rocks,
minerals, water, and geologic processes such as volcanic eruptions, earthquakes and dust.

Medical geology is not strictly an emerging discipline but rather a re-emerging discipline.
The relationship between geologic materials such as rocks and minerals and human
health has been known for centuries. Ancient Chinese, Egyptian, Islamic, and Greek texts
describe the many therapeutic applications of various rocks and minerals and many health
problems that they may cause. More than 2,000 years ago Chinese texts describe 46
different minerals that were used for medicinal purposes. Arsenic minerals for example,
orphiment (As2S2) and realgar (As2S3), were extensively featured in the materia medica
of ancient cultures. Health effects associated with the use of these minerals were
described by Hippocrates (460-377B.C.) as “… as corrosive, burning of the skin, with
severe pain…”

There have been many pioneering collaborations on environmental health issues between
geoscientists and medical scientists (Bencko and Vostal, 1999; Cronin and Sharp, 2002;
Centeno et al., 2002), but these studies have largely been driven by the interests and
enthusiasm of individual scientists. What is different and exciting is that Medical
Geology is now receiving institutional support from many organizations in many
countries.

Practitioners of Medical Geology have five principal responsibilities.

• To identify geochemical anomalies in soils, sediments, and water that may impact
on health.
• To identify the environmental causes of known health problems and, in
collaboration with biomedical/public health researchers, seek solutions to prevent
or minimize these problems.
• To evaluate the beneficial health affects of geologic materials and process.
• To reassure the public when there are unwarranted environmental health concerns
deriving from geologic materials or processes.
• To forge links between developed and developing countries to find solutions for
environmental health problems.
Among the environmental health problems that geologists are working with the medical
community to address are: exposure to toxic levels of trace essential and non-essential
elements such as arsenic and mercury; trace element deficiencies; exposure to natural
dusts and to radioactivity; naturally occurring organic compounds in drinking water;
volcanic emissions, etc. Geoscientists have also developed an array of tools and
databases that can be used by the environmental health community to address vector-
borne diseases, to model pollution dispersion in surface and ground water, and can be
applied to some aspects of industrial pollution and occupational health problems.

TRACE ELEMENT EXPOSURE: DEFICIENCY AND TOXICITY

Trace elements play essential roles in the normal metabolism and physiological functions
of animals and humans. Of these, some 22 elements are known or suspected to be
“essential” for humans and other animals. Some are required in fairly large amounts
(e.g., grams per kilogram of diet), and are therefore referred to as “macronutrients”;
others are required in much smaller amounts (e.g., microgram-to-milligrams per kilogram
of diet and are referred as “micronutrients”. Sixteen elements are established as being
essential for good health. Some (calcium, phosphorus, magnesium, and fluoride) are
required for structural functions in bone and membranes; some (sodium, potassium, and
chloride) are required for the maintenance of water and electrolyte balance in cells; some
(zinc, copper, selenium, manganese, and molybdenum) are essential constituents of
enzymes or serve as carriers (iron) for ligands essential in metabolism; and some serve as
essential components of a hormone (iodine) or hormone-like factor (chromium). Because
these are all critical life functions, the tissue levels of many “nutritionally essential
elements” tend to be regulated within certain ranges, which are highly dependent on
several physiological processes, chiefly by homeostatic control of enteric absorption,
tissue storage and/or excretion. Changes in these physiological processes may exacerbate
the effects of short-term dietary deficiencies or excesses of trace elements.
The sources of trace elements are varied. Food derived from soils is a major, significant
route; however, other sources such as the deliberate eating of soil (geophagia) and water
supplies may also contribute to dietary intake of trace elements. Diseases due to trace
element deficiencies as well as excesses have been described for example, for iodine,
copper, zinc, selenium, molybdenum, manganese, iron, calcium, arsenic, and cadmium.
Endemic distributions of diseases directly related to the geographic patterns of soil
deficiencies in selenium and iodine have been described in at least two general cases, the
juvenile cardiomyopathy “Keshan Disease”and the iodine deficiency diseases goiter and
myxedematous cretinism, respectively. In the following paragraphs, examples of
adversed health effects due to trace element deficiencies and excesses will be described.
Environmental chronic exposure to non-essential elements such as arsenic will also be
described.

Diseases due to Trace Element Deficiences: The connection between geologic materials
and trace element deficiency can clearly be shown for iodine. Iodine Deficiency
Disorders (IDD) include goiter (enlargement of the thyroid gland), cretinism (mental
retardation with physical deformities), reduced IQ, miscarriages, and birth defects. In
ancient China, Greece and Egypt as well as among the Incas, people affected by goiter,
were given sea weed to provide the needed iodine. Goiter is still a serious disease in
many parts of the world. China alone has 425 million people (40 % of the world’s
population) at risk of IDD. In all, more than a billion people, mostly living in the
developing countries, are at risk of IDD. In all the places where the risk of IDD is high,
the content of iodine in drinking water is very low because of low concentrations of
iodine in bedrock.

Selenium is an essential trace element having antioxidant protective functions as well as

redox and thyroid hormone regulation properties. However, selenium deficiency (due to
soils low in selenium), has been shown to cause severe physiological impairment and
organ damage such as a juvenile cardiomyopathy (Keshan disease) and muscular
abnormalities in adults (Kaschin-Beck disease) (see Figure 1). In the 1960s scientists
suspected that the disease was of geological origin and in the 1970s the probable solution
was found. The disease was always located in areas with low selenium soils. The use of
selenium in prevention and treatment of the disease was a great success.

Figure 1: Photos demonstrating cases with severe muscular abnormalities associated

with selenium deficiency in China (Kashin-Beck disease). These photographs were taken
by Prof. Dr. Wang Zhilun (China) a leading researcher on selenium deficiency disorders.

Toxicity of Essential and Non-essential Elements. Toxicity effects from exposure to

excess amount of trace elements have been also described as due, in part, to natural
geological sources. One of the most studied trace elements in this regard has been
fluorine. Fluoride (F-), the ionic form of fluorine, can stimulate bone formation and it
also has been demonstrated to reduce dental caries at doses of at least 0.7 mg/L in
drinking water. However, excess fluoride exposure can cause fluorosis of the enamel
(mottling of the teeth) and bone (skeletal fluorosis).

Health effects from chronic exposure to non essential metals and metalloids such as
arsenic have been also described as an area of research on Medical Geology. Arsenic
and arsenic containing compounds are human carcinogens (IARC, 1987). Exposure to
arsenic may occur through several anthropogenic sources, including mining, pesticide,
pharmaceutical, glass and microelectronics, but the most prevalent sources of exposure
today has been by natural sources. Exposure to arsenic occurs via the oral route
(ingestion), inhalation, dermal contact and the parenteral route to some extent. Drinking
water contamination by arsenic remains a major public health problem. Acute and
chronic arsenic exposure via drinking water has been reported in many countries of the
world, where a large proportion of drinking water is contaminated with high
concentrations of arsenic. General health effects that are associated with arsenic exposure
include cardiovascular and peripheral vascular disease, developmental anomalies,
neurologic and neurobehavioural disorders, diabetes, hearing loss, portal fibrosis,
hematologic disorders (anemia, leukopenia and eosinophilia) and multiple cancers:
significantly higher standardized mortality rates and cumulative mortality rates for
cancers of the skin, lung, liver, urinary bladder, kidney, and colon in many areas of
arsenic pollution (Centeno et al., 2002; Centeno et al., 2002; Tchounwou, 2003) (Figure
2).

Figure 2: Photos showing arsenic-induced lesions of the skin. From left to right:
Keratoric (ulceration) lesions of the foot, leg and hands. Photos: JA Centeno.

Global Implications and Medical Geology Examples of Chronic Arsenic and Fluorine
Poisoning . In Bangladesh, India, China, Taiwan, Vietnam, Mexico, and elsewhere, high
levels of arsenic in drinking water have caused serious health problems for many millions
of people (Kinniburgh and Smedley, 2001). Geoscientists from several countries are
working with public health officials to seek solutions to these problems. By studying the
geological and hydrological environment, geoscientists are trying to determine the source
rocks from which the arsenic is being leached into the ground water. They are also trying
to determine the conditions under which the arsenic is being mobilized. For example, is
the arsenic being desorbed and dissolved from iron oxide minerals by anerobic (oxygen-
deficient) groundwater or is the arsenic derived from the dissolution of arsenic-bearing
sulfide minerals such as pyrite by oxygenated waters? The answers to these questions
will allow the public health communities around the world identify aquifers with similar
characteristics and more accurately determine which populations may be at risk from
arsenic exposure.

In China, geoscientists are working with the medical community to seek solutions to
arsenic and fluorine poisoning caused by residential burning of mineralized coal and
briquettes. Chronic arsenic poisoning affects least 3,000 people in Guizhou Province,
P.R. China. Those affected exhibit typical symptoms of arsenic poisoning including
hyperpigmentation (flushed appearance, freckles), hyperkeratosis (scaly lesions on the
skin, generally concentrated on the hands and feet; Fig. 2), Bowen’s disease (dark, horny,
precancerous lesions of the skin. Chili peppers dried over open coal-burning stoves may
be a principal vector for the arsenic poisoning. Fresh chili peppers have less than one
part-per-million (ppm) arsenic. In contrast, chili peppers dried over high-arsenic coal
fires can have more than 500 ppm arsenic. Significant amounts of arsenic may also come
from other tainted foods, ingestion of dust (samples of kitchen dust contained as much as
3,000 ppm arsenic), and from inhalation of indoor air polluted by arsenic derived from
coal combustion. The arsenic content of drinking water samples does not appear to be an
important factor.

Detailed chemical and mineralogical characterization of the arsenic-bearing coal samples

from this region (Belkin and coworkers, 1997) indicate arsenic concentrations as high as
35,000 ppm! Typically coals have less than 20 ppm arsenic and coals from Malaysia
have less that 5 ppm arsenic (USGS unpublished data). Although there were a wide
variety of As-bearing mineral phases in the coal samples, much of the arsenic was bound
to the organic component of the coal. This observation was important for two reasons.
Firstly, because the arsenic was in the organic matrix, traditional methods of reducing
arsenic, such as physical removal of heavy minerals, primarily as-bearing pyrite, would
not be effective. Secondly, because the visually observable pyrite in the coal was not a
reliable indicator of the arsenic content, the villagers had no way of predicting the arsenic
content of the coals that they mined or purchased. To overcome these problems a field
test kit for arsenic was developed (Belkin et al., 2003). This kit gives the villagers the
opportunity to analyze the coal in the field and identify the dangerous high-arsenic
samples as well as the safer low-arsenic coals.

The health problems caused by fluorine volatilized during domestic coal use are far more
extensive than those caused by arsenic. More than 10 million people in Guizhou
Province and surrounding areas suffer from various forms of fluorosis. Typical symptoms
of fluorosis include mottling of tooth enamel (dental fluorosis) and various forms of
skeletal fluorosis including osteosclerosis, limited movement of the joints, and outward
manifestations such as knock-knees, bow legs, and spinal curvature. Fluorosis combined
with nutritional deficiencies in children can result in severe bone deformation.

The etiology of fluorosis is similar to that of arseniasis in that the disease is derived from
foods dried over coal-burning stoves. Adsorption of fluorine by corn dried over unvented
ovens burning high (>200 ppm) fluorine coal is the probable cause of the extensive dental
and skeletal fluorosis in southwest China. The problem is compounded by the use of clay
as a binder for making briquettes. The clay used is a high-fluorine (mean value of 903
ppm) residue formed by intense leaching of a limestone substrate.

Geophagia is also of concern in medical geology. Geophagy or geophagia can be defined

as the deliberate ingestion of soil, a practice that is common among members of the
animal kingdom, including certain human populations. Soil may be eaten from the
ground but in many situations there is a cultural preference for soil from special sources
such as termite mounds. Geophagia is considered by many nutritionists to be either a
learned habitual response in which clays and soil minerals are specifically ingested to
reduce the toxicity of various dietary components or as an in-built response to nutritional
deficiencies resulting from a poor diet. Geophagy is attaining renewed and serious
interest within the scientific research community.
One particularly interesting case of high element exposure is “sickness country” in
Australia. This area in the Kakadu region of the Australian Outback has been known by
the aborigines as an area that will cause sickness. Hence the area is regarded by the
aborigines as taboo and should not be entered.

Geochemical researchers may have found the reason for the sickness. The bedrock in the
region consists of granites and volcanic rocks. These rock types contain elevated amounts
of certain elements. The “sickness country” contains localized areas of unusually high
natural levels of thorium, uranium, arsenic, mercury, fluorine, and radon in groundwater
and drinking water. The aborigines had also used ochre as color pigment in painting. The
ochre was shown to contain extremely high contents of uranium, lead, arsenic, and
mercury. The naturally high levels of toxic elements in the land and water systems thus
constitute a health hazard recognized eons ago by the local people.

There can also be potentially hazardous exposure to natural gases such as radon. Geology
is the most important factor controlling the source and distribution of radon. Relatively high
levels of radon emissions are associated with particular types of bedrock and unconsolidated
deposits, for example some, but not all, granites, phosphatic rocks, and shales rich in organic
materials. The release of radon from rocks and soils is controlled largely by the types of
minerals in which uranium and radium occur. Radon levels in outdoor air, indoor air, soil
air, and ground water can be very different. Radon released from rocks and soils is quickly
diluted in the atmosphere. Concentrations in the open air are normally very low and
probably do not present a hazard. Radon that enters poorly ventilated buildings, caves,
mines, and tunnels can reach dangerously high concentrations.
NATURALLY OCCURING ORGANIC COMPOUNDS IN DRINKING WATER

Balkan endemic nephropathy (BEN) is an irreversible kidney disease of unknown origin,

geographically confined to several rural regions of Bosnia, Bulgaria, Croatia, Romania,
and Serbia. The disease occurs only in rural areas, in villages located in alluvial valleys
of tributaries of the lower Danube River. It is estimated that several thousand people in
the affected countries are currently suffering from BEN and that thousands more will be
diagnosed with BEN in the next few years.

Many factors have been proposed as etiological agents for BEN, including: bacteria and
viruses, heavy metals, radioactive compounds, trace element imbalances in the soil,
chromosomal aberrations, mycotoxins, plant toxins, and industrial pollution (Tatu et al.,
1998). Recent field and laboratory investigations support an environmental etiology for
the disease, with a prime role played by the geological background of the endemic
settlements (Feder et al., 1991; Tatu et al., 1998; Orem et al., 1999). In this regard, there
is a growing body of evidence suggesting the involvement of toxic organic compounds
present in the drinking water of the endemic areas. These compounds are believed to be
leached by groundwater from low rank Pliocene lignite deposits, and transported into
shallow household wells or village springs. Analysis of well and spring water samples
collected from BEN endemic areas contain a greater number of aliphatic and aromatic
compounds, and in much higher abundance (>10x), compared to water samples from
nonendemic sites. Many of the organic compounds found in the endemic area water
samples were also observed in water extracts of Pliocene lignites, suggesting a possible
connection between leachable organics from the coal and organics in the water samples.

The population of villages in the endemic areas uses well/spring water almost exclusively
for drinking and cooking, and is therefore potentially exposed to any toxic organic
compounds in the water. The presumably low levels of toxic organic compounds present
would likely favor relatively slow development of the disease over a time interval of 10
to 30 years or more. The frequent association of BEN with upper urinary tract (urothelial)
tumors suggests the action of both nephrotoxic and carcinogenic factors, possibly
representing different classes of toxic organic substances derived from the Pliocene
lignites. Pliocene lignites are some of the youngest coals in the Balkans and are relatively
unmetamorphosed in the endemic areas. They retain many of the complex organic
compounds contained in the decaying plant precursors (Feder et al., 1991; Orem et al.,
1999), and many kinds of potentially toxic organic compounds may be leached from
them.

In the Pliocene lignite hypothesis for BEN etiology, however, other factors besides the
presence of low rank coals must also be in play. The hypothesis also implies many or all
of the following circumstances: the right hydrologic conditions for leaching and transport
of the toxic organic compounds from the coal to the wells, a rural population largely
dependent on untreated well water, a population with a relatively long life span (BEN
commonly becomes manifest in people in their 40s and 50s), a relatively settled
population for long exposure to the source of nephrotoxic/carcinogenic substances, and a
competent and established medical network for recognition of the problem and proper,
systematic, diagnosis.

It may be that BEN is a multifactorial disease, with toxic organics from coal being one
necessary factor in the disease etiology. The challenge to researchers is to integrate
studies among disparate scientific disciplines (medicine, epidemiology, geology,
hydrology, geochemistry) in order to develop a reasoned conceptual model of the disease
etiology of BEN.

NATURALLY OCCURRING DUSTS

Exposure to mineral dusts can cause a wide range of respiratory problems. These
exposures can be due to local conditions such as the dusts generated by mining hard
rocks or coal, use of fine-grained mineral matter in sand-blasting, and formation of
smoke plumes from fires (both natural and man-made). Dust exposure can affect broad
regions such as the dust stirred up by earthquakes in the arid regions of the southwestern
U.S. and northern Mexico. This dust carries spores of a fungus (coccidiomycosis
immetus) that causes Valley Fever, a serious respiratory problem that can lead to fatigue,
cough, fever, rash, including damage to internal organs and tissues such as skin, bones,
and joints. Dust exposure can even take on global dimensions. Ash ejected form volcanic
eruptions can travel many times around the world and recent satellite images have shown
wind blown dust picked up from the Sahara and Gobi deserts blown halfway around the
world. Of greatest concern for effects upon human health are the finer particles of the
respirble (inhalable) dusts. On this regard, considerable work is beung conducted in
identifying dust particles derived from soils, sediments and weathered rock surfaces.

Asbestos is a term that represents a diverse group of minerals that have several common
properties; they separate into long thin fiber, are heat resistant, and are chemically inert.
In the 1980s it was recognized that exposure to respirable asbestos fibers can cause
severe health problems such as mesothelioma, lung cancer, and asbestosis. Many mines
producing commercial asbestos were closed and a concerted effort was made to remove
asbestos from schools, work places, and public buildings.

Unfortunately, the problem did not end there. Recently, it was found that small amounts
of asbestos associated with commercial deposits of vermiculite, a micaceous mineral used
for insulation, packaging, kitty litter, and other applications, had caused significant health
problems in the mining community of Libby, Montana, USA (Van Gosen and others,
2002). Lung abnormalities (such as pleural thickening or scarring) occurred in about 18
percent of the adults tested.
 • 100’s of millions of tons of intercontinental dust is deposited annually.
• This dust is increasingly viewed as a key component of some terrestrial
and marine ecosystems, as well as a potentially significant source of
pathogens and environmental contaminants.

Figure 3. This satellite image shows a dust cloud from North Africa moving across the
Atlantic Ocean, over northern South America and then over the Caribbean and the
southern U.S. These dust storms occur several times a year resulting in increased
incidence of asthma and allergies in the Caribbean region. The dust is not exclusively
fine mineral grains. Researchers have found more than 140 different organisms
hitchhiking from Africa to the Western Hemisphere.

CONCLUSIONS

Medical Geology should be considered as a component of Malaysia’s National Health

Action Plan (NEHAP; Pillay et al., 2003). Pillay et al. state that “Environmental health is
the science of protecting human health from the damaging effects of physical, chemical
and biological agents in the environment. This science strives to identify harmful agents,
determining exposures relating to deteriorating health conditions and to develop sound
principles, strategies, programs and approaches to eliminate or minimize health risks.”
Medical Geology has the same objectives but focuses on the naturally occurring physical
and chemical agents in the environment. Thus, for NEHAP to be most effective the
Malaysian geoscience community should be included as one of the key players or
agencies involved in environmental health activities.

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