EPIDEMIOECOLOGY NEWS 

Volume 1, No.3 November 1, 2002 

Featured Article

Weathered Lignite Deposits and Balkan Endemic Nephropathy 

 Gerald L. Feder 

Balkan endemic nephropathy (BEN) is a fatal kidney disease that is known to occur only in 

geographically discrete areas of the Balkan Peninsula in Eastern Europe. The disease was first described in 

1956, but may have existed for many centuries. The disease seems to occur only in rural villages located on 

alluvial valleys of tributaries of the lower Danube River (Figure 1). Although the disease is apparently 

geographically restricted to a relatively small area, BEN is a significant public health problem. At least 25,000 

people are believed to be suffering from BEN, and over 100,000 people may be at risk. Researchers have been 

trying to determine the cause(s) of BEN for almost half a century, but there is still no consensus among the 

scientific community as to its etiology. Some local villagers feel that mysterious cosmic powers are 

responsible, and wear protective amulets or pendants and perform ritual prayers to ward off the disease. 

Western medicine generally opines that certain environmental exposures, genetic predisposition, and/or an 

infectious agent is the more likely cause. (Continued on page 2)

Editorial Column

An estimated 300 to 500 million cases of 

malaria each year cause 1.5 to 2.7 million deaths, 

more than 90% of those in children under 5 years of 

age. Malaria accounts for about 2.5% of all global 

disease. The estimated annual direct and indirect 

costs of malaria are on the order of US$1.8 billion. 

Because we thought that we had eradicated malaria 

from this country, those staggering statistics don’t 

have much of an impact on many of us. But they

probably do to a 15-year-old young man and a 19-

year-old woman in Loudon County, about 10 miles 

from Reston, Virginia. These two teenagers 

contracted malaria about two months ago. Unlike the 

60 or so cases of malaria reported to the Virginia 

Department of Health annually, or the approximately

1,200 cases reported to the Centers for Disease 

Control and Prevention (CDC) for the whole country

every year, these two individuals seem to have been 

infected by local mosquitoes. Most Americans that 

get malaria acquire the infection while on travel in a 

part of the world where malaria is endemic. But now 

we face the prospect that malaria is back, or that it 

never even went away. As if we didn’t have enough 

to worry about in the metropolitan Washington, D.C. 

area, what with snipers, West Nile virus, and anthrax 

letters. 

Since August, mosquitoes in Virginia and on a 

Maryland island on the Potomac River have been 

tested and found to be carrying the malaria parasite. 

There are two kinds of malaria, falciparum and vivax. 

Fortunately, the generally non-lethal vivax form is the 

only one that has been found here so far. The most 

likely explanation for how these mosquitoes became 

infected is that an infected traveller or immigrant 

came to the area, possibly flying into nearby Dulles 

International Airport, and was bitten by mosquitoes 

while still having sufficient parasites in their blood. 

Not all mosquitoes are competent vectors, but as luck 

would have it, we have two species of anopheline 

mosquitoes that are. Some have suggested that 

malaria was never completely eliminated from this 

area, and that perhaps it has been hiding in some nonhuman reservoir. It is not uncommon for zoos to have 

occasional cases of bird malaria, and perhaps the 

parasite has mutated to become infective to humans. 

There have been three other instances of probable 

mosquito-transmitted, locally-acquired malaria in the 

US since 1999: one in Georgia, one in New York, and 

one here in Virginia. If nothing else, this experience 

reminds us that we ought not ignore health problems 

of the developing world. 

For contributions toward the Editorial Column or Featured Article please contact Joe Bunnell: jbunnell@usgs.gov ; 703-648-6497. 1
Epidemioecology News’ Volume 1, No 3 

Featured Article continued.... 

Figure 1. In the early 1990’s 

USGS scientists noted the close 

geographic correspondence 

between endemic areas (yellow) 

and Pliocene lignite deposits in

Yugoslavia (red).

 the lack of any specific sign, or marker of 

s history are in keeping with BEN is the 

 BEN than is currently recognized. Autopsies are 

 BEN as the cause of death. The 

 areas now undergo new sophisticated 

oper diagnosis of BEN. 

 a sustained search for its 

Figure 2. A typical panorama of a 

Balkan endemic nephropathy afflicted 

village from Romania. Usually the 

endemic villages are located in alluvial 

valleys of the Danube River affluents, 

at low elevations (valley bottoms). 

Danube River is located across the 

hills, on the right.

A common geologic feature of endemic villages is the proximity to 

distinctive low rank Pliocene lignite deposits and lignitic shales that were 

deposited about 5.3 to about 1.6 million years ago. Researchers at USGS 

hypothesize that weathering of the lignites and associated shales yield toxic 

soluble organic compounds, and that these toxins are transported by the local 

ground water flow system to the shallow water wells used by the villagers. Figure 

2 shows an alluvial valley typifying the geologic and hydrologic setting of 

endemic home sites. 

Laboratory analysis at USGS of water samples from endemic and nonendemic villages indicate the presence of potentially carcinogenic and 

nephrotoxic organic compounds (Figure 3). These include napthylamines, 

aniline, aminophenols, alkyl phenols, biphenyls, and heterocyclic (N-, O-, and Scontaining) compounds in much higher concentrations in the endemic villages 

than nearby non-endemic villages. 

The disease has several features that characterize it as a distinct clinical 

entity. Unlike the case with many other kidney disorders, BEN patients do not, as 

a rule, have high blood pressure. And a significant number of BEN patients also 

have an otherwise unusual type of upper urinary tract cancer. Only stable, rural populations of people seem to get BEN. 

The stability implies a long “incubation period” for the disease, consistent with ingesting low levels of toxic compounds 

from rural water wells over decades. There are no known cases of BEN among people living in cities and drinking water 

from a municipal supply. Making the diagnosis of BEN is made challenging by

the disease. Only when the particular constellation of symptoms and the patient’

diagnosis made. Thus there could be many more people suffering from

not routinely performed in this region, and only a post-mortem examination can confirm

kidneys are shrunken to about 30% their normal size. BEN patients in some

ultrasound procedures to help confirm the presence of shrunken kidneys, and the pr

The clinical and pathological characterization of the disease has been followed by

causative factors, involving international teams and multidisciplinary

approaches. At present, fatalities from BEN still occur in the same regions, and 

the etiology of the disease is still not known. The main fruits of BEN research, 

up to the present, have come mostly from excluding some fruitless hypotheses, 

and to redirect future investigations and hypotheses. A currently accepted 

concept is that BEN is an environmentally induced disease, and some of the 

most consistently incriminated agents are toxic organic compounds present in 

the drinking water from shallow wells in the endemic areas. Researchers at 

USGS hypothesize that these compounds may be leached by groundwater 

flowing through the nearby low rank Pliocene coal (lignite) deposits, and 

transported into shallow household wells dug into the alluvium. Until the past 

decade, most people in the endemic villages used water from these shallow hand 

dug household wells, for drinking and other purposes. Over the past decade an 

increasing number of endemic villages are getting public surface water supplies, 

piped in to household faucets from regional surface water reservoirs. These 

reservoirs are quite distant from the endemic villages, and are filled by surface 

water runoff that is independent of the ground water system supplying the wells 

in the endemic villages. Moreover, the treatment process for this water renders 

formerly toxic compounds harmless. It will be very useful to study the people in 

these villages to see if the people raised from childhood using piped-in water no 

longer develop BEN. 

One of the characteristics of BEN is that people generally don't develop the disease unless they have lived in an 

endemic village for the first 15-20 years of their life. They then generally won't develop the disease until they are about 

40 to 50 years old. Once they develop the disease, it is fatal, unless they go on dialysis, or get a kidney transplant. Due to 

2
Epidemioecology News’ Volume 1, No 3 

Featured Article continued.... 

the high cost of kidney transplants, and the low economic status of most villagers in the endemic areas, most patients must 

spend the rest of their lives on dialysis. Many BEN cases are reported where a person moves out of an endemic village at 

Seep from Pliocene Lignite in an

Endemic Area, Romania 

Well Water from an Endemic 

Village, Romania 

about 20 years of age, and they are later diagnosed with the disease when they are about 40 or 50 years old. Though the 

correlation between endemic villages and the proximity to Pliocene lignite 

deposits seems to be established, many researchers believe BEN may be a 

multicausal disease. For example, genetic factors may predispose a person to 

develop BEN if they are exposed to certain toxic organic compounds early in 

their lives, or even prenatally. Similarly, it is possible that childhood 

exposure to fungal toxins known to damage the kidneys or infection with 

bacteria that attack the kidneys sets one up for developing BEN. Subsequent 

long term exposure to low levels of toxic organic lignite-derived compounds 

may then seal the person’s fate, leaving unharmed someone with no such 

history.

Spring Water Nonendemic 

(Control) Village, Romania 

Figure 3

While BEN is not known to occur in the United States, it is curious 

that this country’s lignite deposits occur in states with the highest rates of 

cancers of the renal pelvis (RPC). Louisiana has the sixth highest Renal 

Pelvic Cancer (RPC) mortality rate in the United States. Other states with 

major lignite deposits are Wyoming and the Dakotas; Wyoming ranks first in 

the USA for RPC, and North and South Dakota rank third and fourth, 

respectively. All of these states have large rural populations that obtain 

drinking water from wells. A team of scientists from USGS, the Louisiana 

Geological Survey, the Centers for Disease Control and Prevention, and the 

Louisiana State University Medical School have begun investigations 

designed to see if a BEN-like syndrome exists in this country. It will also be instructive to look closely at countries with 

large lignite deposits like Greece and Turkey. However, health data from these nations are sometimes unreliable, and are 

often difficult to obtain. 

While a clear understanding of the cause(s) of BEN remains elusive, there is good reason to be hopeful that we 

will soon identify the risk factors, and enable preventative measures that will 

protect large numbers of people from this illness. This issue represents an example 

of how geoscience experts and the public health and biomedical community need 

to communicate, cooperate, and collaborate to untangle the intricacies of complex 

disease etiologies having an environmental component. That is to say, for all of 

the misery it brings, BEN does seem to be a valuable mechanism for 

Epidemioecologists to demonstrate their worth. 

Jerry Feder, one of the world’s foremost BEN investigators and has retired from

the USGS, but may still be contacted at glfeder@tu.infi.net or gl9202@aol.com. A 

fact sheet summarizing BEN may be found at http://pubs.usgs.gov/fs/fs004-01. Figure 4. BEN Patient from

Southwestern Romania awaiting 

dialysis treatment at a clinic. BEN 

patients are transported every 2 to 3 

days by ambulance from rural

villages to clinics for treatment. 

Many also acquire hepatitis from

overused dialysis equipment.

 

3

Images courtesy of William H. Orem. 
Epidemioecology News Volume 1, No. 3 

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Upcoming Events 

- A Medical Geology textbook being edited by Olle Selinus of the Swedish Geological Survey is making 

progress. Several USGS scientists are participating in this groundbreaking publication, scheduled date for 

publication in early 2003. 

- The American Society of Tropical Medicine and Hygiene, 51st Annual Meeting, will be held on 

November 10 – November 14, 2002 at the Adam’s Mark Hotel in Denver, CO. For more information 

please visit their website at: www.astmh.org/

U.S. Geological Survey News 

USGS Health Conference 

Plans for the USGS National Conference on Health-Related Research are moving forward. We have confirmed 

the exact dates which will be April 1 – April 3, 2003. The Call for Abstracts has been distributed and can be 

found on: http://health.usgs.gov/call_abs.html . The website has been developed for on-line submission of 

abstracts. The on-line registration and lodging is still being developed. Please let your colleagues that might be 

interested in this conference know the URL for this website. 

Human Health web site: 

The USGS human health web site has a new URL: 

http://health.usgs.gov

Please visit the site and provide any updates to Jan Hren (jhren@usgs.gov) 

New listings/links welcome! 

Human Health Sciences and Geosciences: Bridging the Gap, a Topical Session at the annual meeting of the 

Geological Society of America, was held on Monday, October 28, 2002 in Denver, Colorado. The session 

featured a wide range of talks on water quality, dust exposure, biomedical perspectives on geological issues, 

and human health applications of remote sensing and vector ecology. Presenters’ affiliations included USGS, 

US EPA, McGill University, and Purdue University. USGS Mendenhall postdoctoral fellows Joe Bunnell and 

Thomas Ziegler chaired the session. Abstracts may be viewed at: 

http://gsa.confex.com/gsa/2002AM/finalprogram/session_2960.htm.
Epidemioecology News Volume 1, No. 3 

5

 

Epidemioecology in the Media 

(Click on the following logo’s to link to the website. Also click on these to link to that article)

August 28, 2002 Hilary Heason 

NEWS RELEASE: Bangladesh claims against the British Geological Survey

Abstract:

The Natural Environment Research Council (NERC) has received a writ concerning a claim being made against it by a 

number of Bangladeshi residents who allege that NERC was negligent in not testing for the presence of arsenic in 

groundwater while carrying out some research in 1992. The research was carried out by the British Geological Survey

(BGS) and was funded by the British Government. http://www.bgs.ac.uk/scripts/news/view_news.cfm?id=116

July 14, 2002 Barry Bearak

Bangladeshis Sipping Arsenic as Plan for Safe Water Stalls 

Abstract:

The arsenic, a slow, sadistic killer, has just about finished its work on Fazila Khatun. She teeters now. The fatigue is 

constant. Pain pulses through her limbs. Warts and sores cover the palms of her hands and the soles of her feet, telltale of 

the long years of creeping poison. 

Mrs. Khatun is hardly alone in this suffering. Bangladesh is in the midst of what the World Health Organization calls the 

“largest mass poisoning of a population in history.” Tens of thousands of Bangladeshis show the otward signs of the same 

decline. Some 35 million are drinking arsenic-contaminated water, the poison accumulating within them day-by-day, sipby-sip. http://query.nytimes.com/search/abstract?res=F30C10FB34540C778DDDAE0894DA404482

- VITAL SIGNS: CAUSE AND EFFECT; Lessons From a Poisoned Coffeepot 

- Air Testing After Sept. 11 Attack Is Both Perplexing and Reassuring 

- U.S. to Test for Contaminants In 250 Downtown Apartments

- Lung Ailments May Force 500 Firefighters Off Job 

- Uranium in Soil Found at Sites in Balkans 

- Tainted Water Has Little Impact So Far

 

 

Kenneth R. Weiss August 29, 2002 

 

The World; Indoor Stoves Killing Millions in Third World, WHO Says; Health: Leaders at South Africa summit seek to 

end cooking and heating practices among the poor that unleash poisons in their homes. 

Abstract: 

More than half of the world's households cook or heat using unprocessed solid fuels such as wood and agricultural waste. 

In India, about 75% of households use these fuels. Typically they are burned in open fires or primitive stoves, mostly in 

rooms that lack adequate ventilation or chimneys. Without ventilation, women and children around the home are regularly

exposed to high concentrations ... http://pqasb.pqarchiver.com/latimes/

- The State; Angry Town Rejects Taint of Uranium; Health: Idyllwild residents worry that their drinking water has been

contaminated by naturally occurring radiation. 

- Los Angeles; Chromium 6 Removal May Cost $315 Million; Health: Supervisors asked for estimates on cleaning up wells in 

northern L.S. County after high leels of pollutants were detected. 

- THE WORLD; Safety Rules Scarce in China's Factories; Asia: New protections will soon take effect for workers, thousands of 

whom are killed or maimed annually. The injured often cannot support themselves. 
Epidemioecology News Volume 1, No. 3 

6

Eric Pianin March 13, 2002 

Drug Wastes Pollute Waterways; 80% of Streams Checked by USGS Contain Trace Amounts 

Abstract: 

The first nationwide study of pharmaceutical pollution of rivers and streams offers an unsettling picture of waterways 

contaminated with antibiotics, steroids, synthetic hormones and other commonly used drugs. Of the 139 streams analyzed 

by the U.S. Geological Survey in 30 states – including Maryland and Virginia – about 80 percent contained trace amounts 

of contaminants that are routinely discharged into the water in human and livestock waste and chemical plant refuse. 

www.washingtonpost.com/wp-adv/archives

- Traffic Signal Re-Timing Approved to Help the Air 

- Water, Water Some Place; Drought’s Variations Causing Cracks in Regional Approach 

- Study Says Long-Term Exposure Also Can Cause Respiratory Illnesses 

Amanda Gardner August 11, 2002

Some workers face higher asthma risk 

Abstract:

Asthma is more than merely a genetic problem, a new study suggests. Workplace elements also matter: Entertainmentindustry workers such as artists, designers and photographers have an asthma risk five times greater than average workers, 

and farmers, forestry workers, teachers, truckers and health-sector employees face double the risk. 

http://pqasb.pqarchiver.com/chicagotribune/

- Waste facility opposed by Kirk; Mercury in lake near Waukegan a major concern 

- EPA tests wells in Downers Grove 

The editors of this newsletter welcome 

- Suggestions on what to include in future newsletters 

- Suggestions on the newsletter format 

- E-mail addresses of USGS people who may be interested in receiving copies of the newsletter. (Note: 

 subscribers will receive e-mail notification of future editions of the newsletter that will be posted on a USGS 

website). 

- Contributions toward Upcoming Events or U.S. Geological Survey News 

**For comments and feedback please contact Samara Holtzman: sholtzman@usgs.gov: 703-648-6479.** 

 

(The editors of the Epidemioecology Newsletter value any input through their readers. 

 Please don’t hesitate to contact us at anytime and thank you for your replies.)
Epidemioecology News Volume 1, No. 3 

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In The Next Issue 

Just when you thought it was safe to go back in the water ...

Regulations for maximum contaminant levels in water supplies

are based on toxicological studies of individual compounds.

Now we are finding that most water contamination involves

complex mixtures. Learn about this, what the USGS Toxic

Substances Hydrology Program is doing about it, and other

emerging water quality research issues.