ICSBE/14 PROCEEDINGS: Special session on Climate Change, Community-Environment and Ecosystem, and Environmental Pollution, and Chronic Kidney Disease in North Central Province of Sri Lanka [ICSBE/14]: th 5 International Conference on Sustainable Built Environment 2014, Kandy Sri Lanka, 244-520, 2014.
ENVIRONMENTAL POLLUTION-ASSOCIATED CHRONIC KIDNEY DISEASE OF MULTI-FACTORIAL ORIGIN IN SRI LANKA (CKDmfo) Sunil J. Wimalawansa, MD, PhD, MBA, DSc Professor of Medicine Endocrinology & Nutrition, Cardio-Metabolic Institute Somerset, New Jersey, U.S.A. [email protected]
Abstract: Non-communicable chronic diseases are escalating in many developing countries, including Sri Lanka. Chronic kidney disease (CKD) of multi-factorial origin (CKDmfo) [also known as CKD-unknown origin (CKDuo)] first appeared in the late 1990s in the North Central Province and is now spreading outside this region in Sri Lanka. Despite a decade of intense research, the cause(s) of this deadly disease remains unknown. Multiple causes have been postulated with possible association but not causality. In fact, none of the factors postulated to date could singly, at their reported contamination levels, likely to cause renal failure of this type and magnitude or explain the geographical distribution of the disease. A well-planned, broad-based, regionwide, multi- disciplinary research program and a surveillance program must be urgently implemented. In addition to the provision of clean potable water to every being in the region, a nationwide effort to control environmental pollution and implement pollution prevention laws is needed, with the goal of eradicating CKDmfo and reducing the incidence of other non-communicable disease in the country. Key Words: Agriculture, Agrochemicals, Cultivation, Environment, Paddy, Poverty, Premature deaths, Renal failure, Water
________________________________________________________________________ 1. Introduction: Chronic kidney disease of multi-factorial origin (CKDmfo) [also known as CKD of unknown origin (CKDuo), and CKD of unknown aetiology (CKDue] is afflicting approximately 400,000 people in Rajarata, killing between 12 to 15 people daily (on average 13/day), mostly male farmers (1, 2). To date, no causality for CKDmfo has been established. This disease is spreading to neighbouring areas of North Central Province (NCP) in the dry zone, and the Badulla, Moneragala, and Hambantota Districts and parts of the North Western Province, exposing an additional 2.0 million people to the risk of contracting this deadly disease (3, 4). 244
Many potential causes have been proposed, including heavy metals (cadmium, arsenic), fluoride, algal and cyanobacterial toxins, agrochemicals, hard water, ionicity (solutes in the water) (5, 6), Ayurvedic drugs, snakebites, leptospirosis, tobacco and illicit liquor, and inadequate water intake (Figure 1) (1, 2, 7-9). However, there is inadequate analytical data and scientific evidence available to assess or confirm any these agents as the cause of kidney failure (10). By themselves, none of the mentioned substances or the mechanisms, to-date, at the exposure levels reported would cause interstitial-tubular kidney failure (11) of this magnitude. However, toxins that have yet to be identified is still is a possibility that may cause the current CKDmfo epidemic (4).
There is growing evidence that water in shallow wells and reservoirs in the dry zone is polluted with toxins, including phosphates because of the indiscriminate and overuse of agrochemicals particularly in the hillcountry. There is evidence that 16 major reservoirs in Rajarata are polluted with high amounts of phosphate (eutrophication), leading to cyanobacterial-algal blooms; the latter may be harmful to living beings (5,
issue, but it encompasses multiple sectors, including agriculture, irrigation, education, trade, environmental protection, water supply, and social services (1). Nevertheless, there are several controversies, some myths, and much confusion about the investigational methodologies, disparities regarding research findings, interpretation of research data, what actions need to be taken, and overall conclusions (1, 14). To overcome these problems, a uniform research methodology that captures a boarder range of possibilities is needed, as is a multi-disciplinary approach covering the entire NCP (4). Although currently, the Department of Health is spending more than 550 million rupees per year for dialysis and acute care of those with CKDmfo, the governmental departments are yet to pay attention to the disease prevention (1). Only few steps have been taken to decrease the disease burden and the number of people affected or to protect those who are not suffering from CKDmfo. Efforts in ground are grossly inadequate and too slow to come by to protect the healthy in the affected communities, preventing them from acquiring the disease. This is one of the most important public health strategy of eradication of this disease, that yet to be implemented. The focus of the study of CKDmfo in Sri Lanka has been diverted from serious environmental, occupational, and water/soil pollution issues perhaps related to agrochemicals, heavy metals, and fluoride or some unknown toxin, to secondary and hypothetical issues, such as algae, glyphosate, hard water, phosphate, and the poisoning of bordering villages in the NCP by former terrorist groups (14). Rather than approaching the disease scientifically, interested parties are forcing the government to make politically motivated decisions that would have no impact on reducing the incidence of CKDmfo in the country.
12), but there is no evidence that these are linked to CKDmfo. Moreover, the up-country vegetable farmers apply 5 to 10 times the fertiliser amounts recommended by the Department of Agriculture (DoA), especially in potato fields. Recent data from the DoA confirmed that, approximately 50% of farm soils have environmentally critical levels of phosphate (13, 14). Soil erosion and runoff carry phosphate, nitrates, and other agrochemicals from these soils into reservoirs in Rajarata, through the diversion of River Mahaweli at Polgolla. Although such toxins may cause ill health, data are inconsistent in supporting any of these as the cause of CKDmfo.
3. Potential causes that have not given attention: Little or no attention has been paid to several other plausible causes of nephrotoxicity (i.e., substances that harm kidneys). Such causes include the overuse of nephrotoxic non-steroidal anti-inflammatory agents (i.e., commonly used painkillers in the country, except paracetamol), the use of illicit drugs and locally
2. The key issues preventing progress: Over the past few years, a number of groups have investigated this issue. CKDmfo is primarily a health 245
brewed alcohol, smoking locally grown tobacco containing higher contents of heavy metals, leptospirosis (a disease that is spread to humans by rodents), secondary effects of agrochemical and petrochemical contamination of water sources, unsafe and hash working conditions, chronic repeated dehydration, longer term consumption of polluted water, and as-yet-unidentified toxins (1).
4. Conclusions and practical ways to eradicate CKDmfo from Sri Lanka:
Even the excess use of paracetamol can decrease the capacity of the liver to detoxify toxins and chemicals, thus exposing the body to higher amounts of toxins (14). Therefore, all medications need to be consuming with caution according to the approved guidelines. Figure 2 illustrates the necessary network to prevent CKDmfo from Sri Lanka. Detailed recommendations to alleviate and eradicate CKDmfo from Sri Lanka are included in the “CKDmfo white paper” that is to be published soon. The authors’ intent is to provide a copy of this white paper (a dynamic, practical, working document) to all health care workers.
To date, no single cause has been demonstrated to be the source of CKDmfo in Sri Lanka.
The CKD in the dry zones of Sri Lanka is an “environmental exposure, occupational disease” caused by “multiple factors” coming together: thus, the terminology, of CKDmfo.
Contamination of food, water, air, soil, and harsh occupational conditions, high exposure to agrochemicals and toxins for long duration, geographical location, and as-yet-unidentified toxins or microbial agents may contribute to the development of CKDmfo.
In practical terms, once acquired CKDmfo is a terminal disease. While kidney transplantation is a definitive treatment (although many are likely to develop similar kind of renal failure if he or she is continue to exposed to the same environment), it is costly and difficult to identify matching donors. Dialysis will prolong lives, but the treatments are inconvenient and costly. Thus, prevention is the best way forward.
The use of appropriate technology to enhance awareness about the disease, pollution prevention, and behavioural changes are an essential part of the prevention program, but these must meet the needs of the people and be simple to teach, understand, and follow.
Provision of clean potable water is essential: Author predicts that the incidence of CKDmfo can be decrease approximately 50% by providing daily access to clean water. Therefore, the most viable, cost-effective, and sustainable water purification method acceptable to a wide spectrum of affected communities in CKDmfo– endemic areas must be implemented immediately. The goal of such a program should be to provide clean water affordably, sustainably, and improve access to clean water to all villagers in the affected and surrounding regions.
An individual village-based, medium-volume reverse osmosis (RO) [e.g., ~20,000 litres a day
(~5,000 gallons a day)] methodology is the currently, the best option for providing clean water to affected and surrounding villages, that would remove all potential toxins. Contrary to the prevailing myths, RO methodology does not add any heavy metals or toxic chemicals to water. Therefore, when the effluent water pumped back into the stream and conquest large dilution, the amounts of contaminants in the stream-water is approximately the same as in the originating water. Thus, taking proper precautions, the use of RO units do not damage the environment (i.e., in environmental terms, it is neutral), and in fact, cleaner than many other water purification technologies.
improving palatability), but will NOT remove any appreciable amounts of the potential toxins or agrochemicals that may associated with CKDmfo. Water softeners also add small amounts of chemicals to the drinking water. Thus, making hard water soft for drinking purposes alone would not prevent CKDmfo in Rajarata.
Low-volume RO units (e.g., ~250 to 1,000 litres a day) are not durable, and generation of clean water, per litre of basis is over five-times costly. The high-volume RO units (e.g., 200,000 litres a day) have its own disadvantages, including high cost and needing additional infrastructure and maintenance costs. Moreover, villagers have to walk on average over 2 kilometres daily to obtain clean water from centrally located RO units. Such would discourage villagers using clean water for drinking and cooking purposes. Thus, both low volume and high volume RO units are not appropriate for the intended purposes in the NCP. Any of the size-exclusion methods, and methods based on surface “adsorption”, such as using pieces of bricks or activated carbon would not remove potential toxins efficiently and should not be relied on to generate clean water for this region. The water purification method must be capable of removing all known potential contaminants efficiently over 95% efficacy. Because the exact causes leading to the development of CKDmfo are unknown, the water purification methods used must be able to remove almost all dissolved, larger molecules and (including unknown) toxins from water. The use of water softeners may reduce the hardness of the water (remove calcium and magnesium, preventing deposits in pipes and 247
While implementing the traditional high quality, durable RO units, new methods must be evaluated, including ozone technologies and others for their suitability to provide clean water in a cost-effective manner. Newer methods that may eventually replace the RO technology in the future should considered.
Encourage to use rainwater harvesting when “suitable roofs” and other means of collecting water are available in individual houses and community properties, and rain is predictable. However, rainfall in the NCP is erratic, with 3- to 6-month droughts in between, which are not sufficient for replenishing neither the groundwater table nor rainwater harvesting tanks. Moreover, when scaled up to provide clean water for village basis, RO units are more than 35-times cheaper than providing individual houses with rainwater harvesting units. While rainwater harvesting is an eco-friendly and attractive mode, it is not a cost-effective option for the provision of clean water in NCP villages.
Provision of clean water alone will only reduce the incidence of CKDmfo by approximately 50%, and by itself is inadequate to eradicate CKDmfo from Sri Lanka. A constructive awareness and education campaign, g together with prevention of environmental pollution need implementing in parallel.
In addition to having an enforceable “master plan of water management,” a clean water and clean air act is essential for Sri Lanka. In addition, all water authorities need to be transparent, responsible, and accountable to the people they serve.
Data available to-date, do not support genetic abnormalities, glyphosate, consumption of hard
water, or any other single entity as the cause of the current epidemic of CKDmfo.
The application of fertilisers must be based on soil requirements. Issuing fertiliser to farmers should be based on judicious soil analysis recommendations done between three to five year periods. This requires a committed, widely available, and affordable soil analytical service. This action alone would markedly reduce excessive fertiliser consumption; a substantial saving for the government on fertiliser subsidy (e.g., an estimated 2 to 3 billion rupees/year of savings, that would offset all costs associated with elimination of CKDmfo from the country).
While eliminating the importation of the upper tier of most toxic compounds, new international standards and quality controls for locally manufactured and imported agrochemicals must be established. In addition, appropriate safe and cost-effective disposal methods for empty pesticide containers; bottles and bags of fertilizer must be arranged.
The government need to propagate environmentally friendly, organic agricultural methodology, reducing the use of chemical fertiliser, and promote sustainable agricultural methods.
Farmers must be educated in judicious and safe use of fertiliser and pesticides, and modes of protecting themselves when using agrochemicals. These actions require effective field-level farmer training, agricultural extension services, similar to DoA had three-decades ago. The current field-level extension worker (“krupanisa”) is insufficient and inadequately trained; these positions need retraining and strengthening.
farming families, while decreasing retail costs to consumers.
Re-creation of the nationwide, agricultural extension program with trained agricultural extension workers brining under the DOA is important. In addition, program must be reestablished for farmers paid adequate prices for their efforts in generating crops. In this regards, bypassing the intermediaries in the trade would have a major impact on the economic stability of 248
Because CKDmfo is likely caused by adverse changes in the geo-water-environment, there is no medical solution to preventing or eliminating this disease. Therefore, the research (and so the funds for research) should focus on prevention of the disease. In this regards, a truly multidisciplinary research programs that cover the entire region (perhaps using cluster sampling) involving the disciplines of agriculture, soil sciences, engineering, social sciences, and preventive medicine must be implemented.
Because farmers continue to die and the incidence of CKDmfo is escalating, “public funds” should be target to “prevention” efforts. Research studies that do not provide direct relief to the residents of Rajarata, including hypothetical, laboratory, or narrow-scope research, should obtain funds from elsewhere.
A long-term surveillance program, together with the clinical care provided locally, and a groundbased, disease-prevention research and clinical program are essential, which should cover all CKDmfo affected areas. These programs should be guided by real-time data collection through broad-based preventive health strategies.
Because of the non-conformity of study designs and data collection, a meta-analysis of existing data (i.e., putting data together to make sensible conclusions) is not feasible. Therefore, uniform research methodologies should be determined and implement, before more public funds are released to support CKDmfo related research.
Continuation of research along the same lines as those conducted over the past few years is counter-productive. Such work is unlikely to generate information on providing effective preventative strategies; identify the agents that cause CKDmfo; or determine the path that is needed to eradicate the disease from the country.
To avoid conflicts within the local scientific community, an independent, non-governmental, supervisory body of qualified senior scientists
(preferably retired scientists) should be appointed and given the responsibility of identifying research priorities and direction; approving protocols; and overseeing all national research programs related to the CKDmfo. This group of scientists (while independent and non-aligned with the National Science Foundation or the National Science Council) should be assembled from a forum of reputable, unbiased technocrats to advise on technical and economic matters of major national interest, much like the National Planning Commission of India.
Useful recommendations made by various groups need to be properly assessed and synthesised, with consideration given to the broader nature of this disease. Guidelines should be constructed to implement the best practices and systems to resolve CKDmfo. Action must be taken immediately to prevent the spread of CKDmfo and decrease the incidence within the affected areas. The current practice of having multiple task forces and the political leadership instructing others on how to prevent CKDmfo is unproductive, misleading and will only prolong the agony of people in the NCP. These failed approaches must be abandoned immediately. Instead of the current inefficient and conflicting system of having multiple governmental organisations, department, and ministries, president should create an independent “CKDEradication Authority” (CKD-EA) reporting and accountable directly to him, without any ministerial involvement or intermediaries.
Most patients with CKDmfo (and the highest number of people who are dying) are men, who are the primary breadwinners of households in the NCP. Thus, it is necessary to create a special government assistance program and implement it across the region to take care of affected families, focusing on children’s education and dietary and nutritional needs.
Over the past ten-years, considering the little progress made by the various government departments, philanthropic organizations would be best suited to implement these extensive preventative programs in Rajarata.
The aetiology of CKDmfo is unknown, but the steps that are needed to overcome the disease are straightforward.
It is critical to set up a region-wide, coordinated, multidisciplinary, long-term research program with a team of “unbiased” scientists who have a proven record of accomplishment to investigate the causes and treatment of CKDmfo and, most importantly, to establish prevention strategies.
The nation should invest more on research and development and arrange postgraduate training abroad, particularly in the environmental and soil sciences and agriculture, to facilitate solving the major issues at hand now and in the future.
5. Practical actions needed immediately: As described, what is necessary is to implement an effective, truly grassroots-level, non-political, diseasepreventative program based on the needs of the people and prevention of environmental pollution and to establish a long-term surveillance program across all affected regions (1). CKDmfo is a national emergency that is affecting not only farmers in Rajarata, but also the local and national economy, well-being and prosperity, and the social structure of the entire country.
Because no single ministry or department is taking responsibility for hazardous materials such as pollutants and toxins in the country, it would be prudent to create a new department, amalgamation, or an authority of “Toxic Substance Control” for Sri Lanka that would fully focus on all local and imported toxic compounds, including routine spot testing of relevant material. The primary function of such an agency should be to take proactive steps to identify and eliminate health risks associated with all toxic substances.
Therefore, all organizations concerned with the plight of people in Rajarata, including public–private partnerships, need to take their leadership and corporate social responsibility roles seriously. The 249
media should voluntarily take part and engage in propagating balanced, non-partisan, rightful information, leveraging it to enhance and intensify messages on CKDmfo and environmental pollution prevention. Such actions will create additional interest among the private and public sectors, promoting environmental protection and improvement of overall health and the well-being of the nation. The final goal is to decrease all non-communicable diseases and eradication of CKDmfo from the country.
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