Mukt Shabd Journal Issn No : 2347-3150

SOCIOECONOMIC IMPACT OF KIDNEY STONE - A Study of Coastal Villages in District,

Dr.A.Dharmendran Guest Lecturer in Commerce, Sethupathy Govt. Arts College, Achundanvayal (PO), Ramanathapuram – 623502, Tamil Nadu.

Mrs.D.Jeeva Asst. Prof. of Chemistry, Dept. of Bio-Chemistry, Caussanel College of Arts and Science, Ramanathapuram (District) – 623523, Tamil Nadu.

ABSTRACT

Ramanathapuram district of Tamil Nadu is a salinity and drought-prone district with an area of 4,175 sq km of these include 2000 sq km of coastal areas. The groundwater is saline in the coastal villages of the district due to seawater intrusion and excessive groundwater extraction. Seawater intrusion has changed the water quality in this district contaminating it with excess salinity and different elements such as chloride, calcium, magnesium, and sodium. This is led to the prevalence of several health hazards in the district namely kidney stones, hypertension, and skin disease. Medical practitioners say that the major reason for kidney stones is the high concentration of calcium in drinking water. This is a major survival issue of lack of access to water more than 68 % of the populations have no access to safe drinking water and this issue is assuming alarming proportion over the year.

The study aims to estimate the sex, age, occupation, prevalence of symptoms, duration of the symptoms and recurrence of kidney stones in the district and understand its varied socioeconomic 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 the prevalence of kidney stones in the six selected study blocks of coastal villages in . The sample survey of coastal villages revealed that 48.38% of the affected persons had the symptom of burning pain while passing urine and 4.84% had the symptom of passed sand-like granules with urine. In these villages, the average medical expense incurred by an affected person was Rs 9309.26 and the average wage loss was Rs 3706.06. Urologists say that about 80 % of kidney stone cases have a chance of recurrence, raising the expenses incurred on treatment even further. Given its high social costs, the problem of kidney stones, thus, deserves immediate attention from concerned authorities.

Key Words: Sex, Age, Occupation, Symptoms, Kidney Stone, Medical Expenses, Wage Loss, Drinking Water Expenses

1. INTRODUCTION

Ramanathapuram is the Coastal district of Tamil Nadu. The Ramanathapuram district has 271 km of the coastline of which 130 km is in Palk Bay and 141 km in the Gulf of Mannar. Out of 11 blocks, six blocks such as Ramanathapuram, Mandapam, R.S.Mangalam, Thiruvadanai, Thirupulani, and are located along the Coastal belt have more than 1000 ppm (parts per million) to 20,000 ppm of Total Dissolved Solids (TDS) throughout the year due to seawater intrusion and excessive groundwater extraction. These six blocks having saline groundwater this is not fit for human consumption. The water in the Wells, Hand pump, Deep bore well, combined water supply, Oorani, and Desalination plant in these worst affected areas were not only potable, but it was also not suitable for cleaning utensils, bathing or washing clothes. When this water was used for construction purposes, large whitish blobs of salt would appear on walls and ceilings. Seawater intrusion has changed the water quality in these blocks contaminating it with excess salinity and different elements such as chloride, calcium, magnesium, and sodium. This has led to the prevalence of several health hazards in these blocks namely kidney stones, hypertension, and skin diseases. There are no population-based data on the

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incidence or prevalence of kidney stones in Ramanathapuram district. Medical practitioners say that etiology (the study of the causes of diseases) of ailments such as hypertension; skin diseases and kidney stone include many aspects and not just increase in salinity. One of the major reasons for kidney stones, however, is the high concentration of calcium in drinking water. The study aims to estimate the prevalence of kidney stones in these blocks and understand its varied socio-economic impacts - expenses incurred in treatment, expenses incurred in procuring good quality water and loss in wages due to the inability to work.

2. STATEMENT OF THE PROBLEM

In this District, the problem of salinity exists both in coastal areas and inland. The formation water is brackish to saline below six to nine meters below ground level in the coastal part of the district and freshwater floats over as lenses. The exact nature and intensity of the problem have, however, not been systematically surveyed in detail. The soils of coastal areas offer many unique problems like salinization, waterlogging, claypan formation, and seawater inundation. The problem of salinity in the coastal area has created a very adverse condition concerning drinking water supply and other aspects of the lives of the people. Seawater intrusion has changed the groundwater quality in contaminating with excess salinity with very high TDS. Consumption and irrigation with this poor quality water can cause a variety of suffering towards human and cattle health and also can reduce the output of agriculture.

The high sodium in seawater ingress may cause hypertension too. There are typical kinds of skin diseases found among the people who are exposed to high salinity water for a long time. The most significant health hazard in the salinity ingress area is kidney stone, which generally takes place due to high calcium, and magnesium available in saline water besides other reasons. Medical practitioners say that the etiology of ailments such as hypertension; skin diseases and kidney stone include many aspects other than only salinity. Therefore it is not always easy to establish salinity as the only cause for all these three kinds of ailments. Though there are other environmental and social reasons like extreme climate, less rainfall, more perspiration and lifestyle of the people, local Doctors say that one of the most important reasons for kidney stone in Ramanathapuram District is the presence of the high amount of calcium and TDS in the water used for consumption. These health hazards due to environmental reasons have an impact on the total development of an area because 'good health is one of the most precious assets of any population, but it is particularly important for populations that are poor and vulnerable.' (Woodward, Alistair, et al, 2000).1 Woodward noted further that "when 'bread-winners' suffer serious ill health or injury, entire households can suffer, not only because of loss of income but also as a consequence of the high direct cost of medical care, a common cause of impoverishment in itself". Thus the weak health of human resources has caused social hardships and several negative externalities such as income inequality, health impacts and the non-sustainability of secondary and tertiary sectors.

Much has been done to study the problem of salinity in terms of individual research efforts and Government efforts by way of appointing High-Level Commission, or Khar Land Development Board and the Coastal Saline Research Centre. Their main focus was on the genesis of salinity problems. Moreover, the efforts were also made at different times either to study the specific salinity condition or assessment of some segments of the coastal area. However, the impact of salinity on human health and socio-economic aspects in the coastal area has not been studied yet specifically in Ramanathapuram District. The impact assessment of coastal salinity on the livelihoods of the people and coping strategies may provide a proper perspective which might be useful to formulate an efficient management plan to support the menace of salinity on health in the coastal area.

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3. OBJECTIVES OF THE STUDY

The study, therefore, tried to focus on the social impact of high salinity, particularly on expenses on medical care for the incidence of kidney stones in the populace. The focus was to understand the prevalence of kidney stones, medical expenses for it, loss in wages due to the inability to work and expenses on good quality water. Therefore our objectives are as follows: 1. To estimate the prevalence of the kidney stone ailments 2. Expenses on medical treatment for kidney stone 3. Loss in wages due to inability to work for kidney stone, and 4. Expenses on good quality water to avoid the vulnerability of health

4. METHODOLOGY

4.1 Data Collection

Since there is no benchmark data for this study, we selected villages from the coastal area. A sample survey was conducted in the coastal villages from the six study blocks of Ramanathapuram district to estimate the prevalence of kidney stone cases using the five most important symptoms based on the discussion with urologists. In this regard, two kinds of data were collected. The first, the prevalence of kidney stones in these study areas were collected into different factors such as sex, age, occupation, the prevalence of symptoms, duration of the symptoms and recurrence. The second, socio-economic data were collected on the impacts of expenses incurred in treatment, expenses incurred in procuring good quality water and loss in wages due to the inability to work. Using a pre- designed and pre-tested questionnaire, both household level and affected person-level data were collected.

4.2 Sampling Design

Purposive sampling was done and hamlet level data were collected from 48 villages from 24 Panchayats of six blocks were selected the sample of 144 households from all the saline affected coastal villages in Ramanathapuram district to estimate the prevalence of kidney stone.

Taking into account the prevalence of kidney stone cases from the sample survey we selected a sample of 144 households with 62 affected persons for a detailed study of tangential expenses explained above from study villages. Her also we have used a structured questionnaire for collecting family details of the affected persons, details of medical expenses including the expenses of the accompanied person/s stayed with the affected person during hospitalization, wage loss of the affected person due to inability to work for his ailment and the accompanied person/s as well for attending the affected person, etc. Table 1 gives the details of the sampling procedure adopted and the number of households selected in each block for data collection.

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Table - 1: Household Questionnaire Survey Sl. Block Name No. of Panchayats No. of Hamlet No. of Affected No. (Revenue Villages) Villages Households Persons 1 Tiruvadanai 5 10 30 13 2 R.S.Mangalam 4 8 24 11 3 Kadaladi 6 12 36 16 4 Ramanathapuram 3 6 18 6 5 Tiruppullani 3 6 18 7 6 Mandapam 3 6 18 9 Total 24 48 144 62 Purposive Sampling Purposive Sampling Purposive Purposive We have (Out of 11 Blocks, 6 (10% of total Sampling (Each Sampling (Each selected the Blocks were selected) Panchayats were Panchayat has 2 Village has 3 affected persons selected) Villages were Households based on the selected) were selected) five symptoms *See Table-2 *See Table-6 Source: Field Data

4.3 Period of Study

There is no recent epidemiological study of Coastal Villages in Ramanathapuram District. To have an idea of the prevalence of the kidney stone disease in Ramanathapuram district an investigation was made on a Sample survey of various factors in the form of the questionnaire. The statistics presented here is a consolidated report of the data collected from June 2019 to December 2019.

4.4 Study Area

4.4.1 Geographical location of the Study Area

Ramanathapuram District is located in the Southern part of TamilNadu State on the East Coast of India. Its geographical location is spread between 9° 05’ and 9° 50’ of North Latitude and 78° 10’ and 79° 27’ of East Longitude. It is bordered by Pudukkottai and part of Sivaganga districts on the northern side, by Sivaganga district on the North Western side and by Viruthunagar district on the west. The district has the East coastline as its eastern boundary parting the district from the Bay of Bengal. Hence the Palk Strait is guarding the district on the eastern side and Gulf of Mannar on the South. The total geographical area of the district is 4,175 sq. km. The district has been divided into 11 blocks (Fig. 1).

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4.4.2 Administrative Profile of Study Area

Ramanathapuram district comprises seven taluks, 11 blocks, and 2362 villages. With repaid to the hierarchy of administrative arrangements, there are two municipalities, seven town panchayats and 429 village panchayats in the district. Further, details of blocks and the number of panchayats and hamlets in each block are presented in table 2.

Table – 2: Blocks and Panchayats Sl. Block Name No. of No. of No. Panchayats Hamlets 1 Tiruvadanai 47 310 2 R.S.Mangalam 35 235 3 Paramakkudi 39 163 4 Bogalur 26 91 5 Nainarkoil 37 113 6 Kamudi 53 346 7 46 169 8 Kadaladi 60 285 9 Ramanathapuram 25 120 10 Tiruppullani 33 240 11 Mandapam 28 200 Total 429 2362 Source: Records of Office of the Collector, Ramanathapuram

4.5 Data Processing

After the completion of data collection, the filled up questionnaires were edited properly to make them ready for coding. A master table was prepared to incorporate all the information available in the questionnaire followed by the

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construction of classification tables with the help of the Microsoft Office Excel Worksheet. The classification tables were used for further analysis.

5. RESULTS AND DISCUSSION

5.1 Gender

Men are at the greatest risk of developing kidney stones with incidence and prevalence rates between two and four times that of women.2 Men were at greater risk of producing calcium oxalate stones and uric acid stones. Women were at greater risk of infection stones. In a separate study by Gault and Chafe in Canada, women were also found to be more likely to produce calcium phosphate stones than men.3 Table 3 shows the gender of the affected persons in the study area.

Table – 3: Gender of the Affected Persons Gender No. of. Affected Persons Percentage Male 42 68 Female 20 32 Total 62 100 Source: Field Data Our analysis of the distribution of the disease in different sex has shown in table 3, out of the 62 cases, 42(68%) are male and 20(32%) are female.

5.2 Age

A 15-year retrospective study by Baker et al.4 found that the peak age for the development of calcium oxalate stones was between 50 and 60 years. Table 4 presents the age of the affected persons in the study area.

Table – 4: Age Group of the Affected Persons Age Group No. of. Affected Persons Percentage Up to 20 2 3.2 21-30 4 6.5 31-40 23 37.1 41-50 25 40.3 51-60 5 8.1 Above 60 3 4.8 Total 62 100 Source: Field Data

The distribution of the disease in different age groups is shown in Table 4. The incidence of urinary calculus is 25(40.3%) high between 41-50 age groups. Next to this, the incidence is 23(37.1%) and 5(8.1%) found to be high in the age group 31-40 and 51-60 respectively. The incidence was lowest among teenagers (below 20 years) and was less in elders (above 60 years). The elders in the series were two male and one female patient of age above 60 years

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and the teenagers was a boy and a girl of below 20 years. Sex distribution in different age groups is high in both sexes between the ages group of 41- 50.

5.3 Occupation

Sedentary occupations, including professional and managerial groups, are associated with a higher incidence of urinary calculi than manual jobs. Stress is also associated with the stone disease.4 Occupation is categorized into active like coolie, farmer, driver, businessman, housewife, and Student. The present study shows that all the affected persons are physically active, shown in table 5.

Sl. Table – 5: Occupation of the Affected Persons No. Occupation No. of. Affected Persons Percentage 1 Coolie 28 45.2 2 Farmer 7 11.3 3 Officer 4 6.4 4 Driver 2 3.2 5 Business 6 9.7 6 Housewife 12 19.4 7 Student 3 4.8 8 Total 62 100 Source: Field Data

Table 5 reveals that among 62 affected persons, 28(45.2) were coolie, 12(19.4) were housewives and 7 (11.3) subjects were in farmer while 6 (9.7) were in business and 4 (6.4) were an officer.

5.4 Prevalence of Kidney Stone Symptoms

Based on discussion with several urologists, we have selected most important primary symptoms for kidney stones, which are 1) pain from loin to the groin, 2) burning when passing urine, 3) passed blood with urine, 4) urination stop in midstream for pain and 5) passed sand-like granules with urine. All these five symptoms are the leading symptoms for diagnosing kidney stones or urinary calculi. However, among these five symptoms, if a person has both symptoms 1 and 5 then he/she would be much sure of suffering from the stone formation in the kidney or anywhere in the urinary system. Urologists say that even 1 or 2 symptoms can be so severe at times that the person may have to go for immediate surgery or intensive medical care. Table 6 presents the Prevalence of Kidney Stone Symptoms in affected persons.

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Sl. Table – 6: Prevalence of Kidney Stone Symptoms No. Symptom No. of. Affected Percentage Persons 1 Pain from Loin to Groin 20 32.26 2 Burning when Passing Urine 30 48.39 3 Passed Blood with Urine 4 6.45 4 Urination Stop in Midstream for Pain 5 8.06 5 Passed Sand like Granules with Urine 3 4.84 Total 62 100 Source: Field Data

It is seen from table 6 in our study 30(48.38%) of the afflicted persons had the symptom of burning pain while passing urine. Many affected persons had loin pain difficulty are 20(32.26%). Some had the problem of passed blood with urine, urination stop in midstream for pain and passed sand-like granules with urine are only 4(6.45%), 5(8.06%), and 3(4.84%) respectively.

5.5 Duration of the Symptoms

The average time of onset of the symptom in affected persons to the time of study period varied from within a month to the last year. Table 7 shows these details.

Table – 7: Duration of Symptoms in Affected Persons Duration No. of. Affected Percentage Persons Up to 3 Months 6 10 4 - 6 Months 20 32 7 – 9 Months 23 37 10 – 12 Months 10 16 Above One year 3 5 Total 62 100 Source: Field Data

Table 7 reveals that 23(37%) of the affected persons have 7 – 9 months of the symptoms of kidney stones (or urinary calculi), 20(32%) have 4 – 6 months of the symptoms of kidney stones, 10(16%) have 10 - 12 months of the symptoms of kidney stones, 6(10%) have up to 3 months of the symptoms of kidney stones and 3(5%) have more than one year of the symptoms of kidney stones.

5.6 Medical Expenses and Wage Loss

5.6.1 Selecting Affected Persons

We carefully selected the affected persons from the sample survey after estimating the prevalence of symptoms one and five both (we are referring the symptoms by numbers given in Table – 6 above) and a few of them are with a combination of all symptoms, 1 to 5. First, we preferred to select from the cases with both the symptoms (1 and 5) because this combination signifies a definite presence of kidney stones and then from the mix of other symptoms

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taking prevalence into account. Many cases have been dropped, as those cases were not having the symptoms concerning stone. Many people complained during sample surveys about their pains related to the urinary stone understanding that they may take some treatment from the hospital. Those persons were selected for our study. Thus we selected 144 households; some households have two affected persons, so we have a total of 62 affected persons with kidney stone-related complaints.

5.6.2 Medical Expenses for Kidney Stone Disease

Indeed, the stones in kidneys do not form overnight or by a couple of months. However, there are exceptions. People do not visit doctors for initial pains rather they take “grandmother’s remedy” initially. Pain does not occur at the initial stage especially if the stone is located inside the kidney. However, if the stone is in the ureter, the duct carrying urine to the bladder, there will be pain signals in the area of Right and Left Upper Quadrants, people go to visit doctors or Ayurveda at this stage. The medical expenses start from this stage. We have collected these expenses in terms of pre-treatment and post-treatment expenses. The expenses include – operation fees, hospital-stay fees, and medical expenses during operation, pre and post-operation medicine expenses, transport expenses from village to hospital and expenses of stay for accompanied person/s and also their loss of wages if any. We have collected these expenses as many details as possible from the affected persons irrespective of where they have been patients.

Table – 8: Income, Medical Expenses, and Wage Loss Medical % of No. of Wage Monthly Annual Expenses Med Affected Loss of Sl. No. of No. of Income Income of of Exp. to Persons Affected No. Househ Affected Groups Household Affected Total Reported Persons olds Persons (Rs) s (Rs) Persons Annual Wage (Rs) (Rs) Income Loss 1. Up to 2000 20 8 360000 63181 17.55 4 12200 2. 2001- 4000 76 31 2658146 260435 9.80 14 52540 3. 4001- 6000 31 14 1810764 167358 9.24 5 20188 4. 6001- 8000 7 4 588000 36900 6.28 2 8467 8001- 5. 4 3 432000 23800 5.51 1 3750 10000 10001- 6. 4 1 540000 16500 3.06 1 3525 12000 Above 7. 2 1 330000 9000 2.73 1 3100 12000 8. Total 144 62 6718910 577174 8.59 28 103770 Per 9. Affected 9309.26 3706.07 Person 10. Per HHs 46659.10 4008.15 720.63 Source: Field Data

The affected persons of saline villages have spent more on their medical expenses. It is for their affordability. The average expense per affected persons in the saline area is Rs 9309.26. The average medical expenses are found nearly 8.59% of their total income among the selected sample household in saline villages; the range was from 2.73% to 17.55%, and in the lowest income group (Upto Rs 2000) it has gone up to 17.55% (Table eight). Among the households of the saline area, it is observed that the percentage of medical expenses is higher in lower-income groups than in the higher income groups. It is obvious as they cannot take care of their regular health care, so they

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when fall sick, they have to spend as much as they can for their cure. Therefore the afflicted families particularly from the saline area may have to spend again and in the future unless they can change the water quality they drink, which may be the major cause for kidney stones of this district.

5.6.3 Wage Loss for Kidney Stone Ailments

The average annual income per household in saline area families is less than Rs 50,000. All the affected persons have not lost their wages since many of them were not earning members. Among 62 affected persons from the saline area, only 28 persons reported their loss in wages. Thus per reported person wage loss in the saline area was found as Rs 3706.07 (Table 8).

5.7 Expenses on Buying Drinking Water

In general, people use the village sources for drinking water, either from Panchayat supplied one or from irrigation wells nearby. The characteristics of groundwater in the phreatic aquifers in Ramanathapuram district, in general, are colorless, odorless and slightly alkaline. The specific electrical conductance of groundwater in the phreatic zone (in Microseimens at 25o C) during May 2006 was in the range of 409 to 4350 in the district. It is between 750 and 2250μS/cm at 25oC in the major part of the district.

In saline villages, people buy water daily for about 365 days in a year at the rate of Rupees six to Rupees eight per pot of 20 Litre ordinary Drinking Water. Its water quality is questionable because the water is brought from wells of nearby villages where water is comparatively less saline. The expense of this drinking and cooking water is Rupees six (minimum), assuming the lower price of Rupees six we get Rs. 2190 per year per family for five members in a year. The people from the non-saline area do not spend this amount or maybe spending very rare in some drought years. Families, who have an underground water tank, are also to buy one or two tanks full of water every year at the rate of Rs. 300 to Rs. 600 per tanker of 3000 to 6000 liters of water.

6. CONCLUSION AND SUGGESTION

1. The intrusion of saline water from the sea has increased the salinity of groundwater. The main sources of irrigation in these areas are rainwater and groundwater. Saline groundwater is used when rainwater is scarce for irrigation; the salinity has reduced the productivity of agriculture, particularly the crop of paddy. At the same time, farmers are depending mostly on one crop cultivation. This has reduced their income. So we suggest to farmers are changed their one crop cultivation pattern to a mixed crop cultivation pattern.

2. Rich people, who had opportunities left the village and settled in the sweet water area. Those who could not stay in the village with hardship. They depend on the farm and non-farm labor in and outside their village.

3. Coconut and mango farming were damaged very severely due to salinity. The fruits of coconut got shrunk by one third and could fetch very less now. In the coconut grove is not much visible now, which were plenty a few years ago, they say. Thus the income of these coconut and mango orchard owners is reduced.

4. Apart from these impacts on agriculture, there is an impact on health due to high salinity. Nearly five percent of people are afflicted by kidney stones in the saline area villages. In the selected households from the villages of the saline area, we have per household annual income is Rs 46659.10, per household (a) medical expense is Rs 4008.15, (b) wage loss Rs 720.63 and (c) water cost Rs 2190; hence the total of (a),

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(b) and (c) is Rs 6918.78 which is about 14.83% of the per-household income when there is one affected person in the home. In some individual families, the ratio of expenses to income is very high, depending upon the severity of the ailment. There is an 80% percent chance recurrence of kidney stones. Preventing recurrence, after stone clearance has been achieved, is a key part of managing the stone disease, If the 'bread-earner' of a family suffers from kidney stone ailment then the family’s overall economy becomes further worse.

5. Though the cause of kidney stones is very complex and wide, in the area of study the major cause is the presence of a high amount of TDS and calcium in the drinking water. The environment of extreme climate, sweating, and food habits of people, intake of lime with ‘masala’, not drinking sufficient quantity of water accelerates the formation stone in the kidney.

6. The underground water storing tank is located only in the families of a few affected persons with kidney stones. Setting up an underground water tank is not possible for all families because it is expensive. Families, who have an underground water tank should not only use purchased water but also harvest rainwater during the rainy season, doing so will reduce the cost. At this time, it is better if the underground water storage tank is set up with a government grant in this study area.

7. Besides all these, there are impacts on social aspects also. The migration of families from saline villages to non-saline villages has increased. This social impact is difficult to quantify. A high tendency of migration was observed among the people of saline villages. Identifying the cost of the high incidence of kidney stones due to high salinity and other impacts on agriculture and society, the problem deserves to get immediate attention from concerned authorities before it gets further worse.

7. REFERENCES

1. U S DEPARTMENT OF HEALTH AND HUMAN SERVICES, National Institutes of Health Woodward, Alistair, Simon Hales, Navitalai Litidamu, 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”, Bulletin of the World Health Organisation, pp 1148-55 www.kidney.nih.gov 2. Hiatt RA, Dales LG, Friedman GD et al. Am J Epidemiol 1982; 115: 255-65. 3. Gault MH, Chafe L. J Urol 2000; 164: 302-7. 4. Baker PW, Coyle P, Bais R et al. Med J Aust 1993; 159: 390-92. 5. G Madhurambal, N Prabha and S Ponsadi Lakshmi, (2012) “Epidemiology of Urinary Stones”, Research Journal of Pharmaceutical, Biological and Chemical Sciences(RJPBCS), Volume 3, Issue 4, October – December 2012, pp.837-846. 6. Pandi Lakshmi, C.D.Lethi and P. Kokilavani, (2013) “Identification of Calcium oxalate Crystal Deposition at Different Periods, Major Crystal Adherence Sites and its Injuries in Ethylene Glycol Administered Male Albino Rat Kidneys”, Indian Journal of Natural Sciences, Vol.4, Issue 20, October 2013, pp.1387-1414. 7. District Agriculture Plan - Ramanathapuram District, (2008), National Agriculture Development Project, Centre for Agricultural and Rural Development Studies, Tamil Nadu Agricultural University, Coimbatore. 8. Johnson, B., Shyam.S.Salim and Narayanakumar, R., (2013) “Market Structure Analysis of Fish Markets in Ramanathapuram District of Tamil Nadu”, Marine Fisheries Information Service T&E Ser., No. 217, 2013, pp. 1-3. 9. Jayalakshmi et al., (2014) “Statistical Interpretation and Groundwater Management Plan at the Extreme Ends of Pamban Bridge, Tamil Nadu, India” World Journal of Pharmacy and Pharmaceutical Sciences, Vol. 3, Issue 6, 2014 Pp.1376-1390. www.wjpps.com

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10. Report on Development of Coastal Areas Affected By Salinity, (1981) National Committee on the Development of Backward Areas, Planning Commission, Government of India, New Delhi, November 1981. 11. A.Balachandran, Scientist-D, (2009) “District Groundwater Brochure Ramanathapuram District, Tamil Nadu”, For Official Use Technical Report, Government of India, Ministry of Water Resources, Central Ground Water Board, South Eastern Coastal Region, Chennai, April 2009. 12. Vasudha Pangare and Oihos, (2003) "Impact on Livelihoods: Rejuvenating 'Oorani' Watershed Development Initiative Ramnad District, Tamil Nadu, India,” An IWMI Research Project Supported by DFID-UK, June 2003.

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