23 October, 2017

Jaffna Awaits The Silent Killer: Chronic Kidney Disease

By Annahl Anbini Hoole

Annahl Anbini Hoole, MD

Chronic Kidney Disease (CKD) is a non-communicable disease that affects 10% of the global population to some degree, but goes undiagnosed till the later, more dangerous stages when symptoms appear. Numbers are rising disproportionately in Sri Lanka, especially of CKD of unknown etiology (CKDu – meaning no one knows the cause).

The Sri Lankan Government therefore set up a Presidential Task Force on CKDu in 2014. Although it was thought to affect mostly older, male agricultural workers who are chronically exposed to pesticides and other chemicals, there is now an increase in cases among children and females. With more than 15% of the population in the North Central and Uva Provinces affected, CKDu is now spreading to the Northern, Eastern, North Western, Central, and Southern Provinces.

To prepare the people in the Northern Province, the Lions’ Club has come forward to raise awareness and has begun a fund to help people. They also organized this public health awareness seminar on CKD at the District Secretariat Auditorium in Nallur on March 15, 2017.

Lion R. Rakini, Lions’ Club Nallur President delivered the welcome address and Lion Dr. V. Thiyagarajah, the 306 B1 Centennial District Governor, gave the keynote address and distributed informational leaflets.

The Kidneys:

We all have two kidneys that are about the size of your fist and lie in the middle of your back on either side of your spine. The kidneys’ main jobs are to filter our blood by removing waste products and extra water through urine. They help control blood pressure, make red blood cells, and maintain healthy bones.  They also filter out waste products from our food, drink, medicines, and breakdowns from muscular activity. 

Chronic Kidney Disease (CKD):

In CKD, the kidneys are damaged and cannot complete their job. It happens over the course of 5 stages, with symptoms not showing until later stages. As the stages progress your blood pressure might increase, you might have low red blood cells (anemia), weak bones, a change in urine and its output, swelling feet, fatigue, and back pain. These can eventually lead to kidney failure and death. There has been a 134% increase in deaths resulting from CKD worldwide, with incidence of end stage renal disease more than doubled at the Teaching Hospital, Jaffna in 2012-2015. Dr. V.G. Rajeev (Regional Epidemiologist), standing in for Dr. Nanthakumar, Regional Director of Health Services, pointed out that deaths caused by non-communicable diseases (like heart disease, diabetes, and kidney disease) now surpass those by other non-communicable diseases (like dengue and malaria).

From left to right: Dr. R. Surenthirakumaran, Dr. T. Saththiyamoorthy, Mr. Alvapillai Siri,  Dr. V. Thiyagarajah, Mr. V.Niranjan, Dr. V. Rajeev, Dr. Ranga Weerakkody

Prevention:

Dr. T. Peranantharajah, Consultant Physician for the Teaching Hospital gave a folksy, entertaining talk on prevention. Along with regular checkups with your doctor, a healthy lifestyle can prevent you from getting kidney diseases, manage your risk factors, and slow down the progression of kidney disease. He talked about the importance of managing what you put into your body. Poor eating habits, smoking, drinking alcohol, and obesity are all associated with kidney disease. Dr. Peranantharajah recommended a whole-grain (preferably vegetarian) diet, with lots of non-chemically treated fruits, nuts, legumes, and vegetables and less sodium, sugar, and red meats. He condemned white foods except milk. Another important lifestyle change is increasing our physical activity. As he says “Our society is plagued by an addiction to cereals: we start our day with cereals, then come home after work and plunk ourselves in front of our  TV set watching mega-serials.”

He recommends walking at least a half an hour every day, as well as making small changes like taking the stairs instead of the elevator, getting down two bus-stops earlier so we have to walk. Cars promote health better than motorbikes because you cannot park at the entrance and need to walk. It is not enough; however, to saunter from one house to the next house, stopping at each gate to pick up on the latest news as seems the customary Jaffna “exercise”. By exercise, he means varying your pace and walking fast enough to increase your heart rate. “Even if there is no god, it’s good to believe in god so we can walk to the temple,” he says. To re-activate our muscles, traditional kitchens with ammis, urals and kappis are better than grinders, mortars, and pumps, respectively, he advises.

Lose weight if you must; keep your body mass index within a healthy range. For obesity check, a rough calculation by him is height in cm minus 100 should be our weight in kg. Stop smoking if you are a smoker, and limit how much alcohol you drink. Another important point he brought up was to not take more medication (i.e. NSAIDs like aspirin, ibuprofen, and naproxen) than recommended by your doctor, as filtering these is a burden on your kidneys.

Dr. Peranantharajah also urged everyone to drink more water, not colored drinks or soda, just clean, pure water. Many avoid drinking water so we don’t have to go to use a public bathroom. However, holding your urine and not drinking enough water can cause urinary tract infections, which if recurrent and untreated can lead to kidney damage. By drinking enough water, your kidneys can use that water to filter out waste products through your urine.

Risk Factors:

Dr. R. Surenthirakumar, head of Community and Family Medicine at University of Jaffna, presented his research done with students at the Teaching Hospital. It showed that diabetes and hypertension are the biggest risk factors among newly diagnosed CKD patients in 2014, followed by an unknown cause (CKDu), renal calculi, and recurrent urinary tract infections. CKDu is not associated with common risk factors like diabetes or hypertension. He also found that Jaffna (specifically in Nallur, Karainagar, and Delft) has the most newly diagnosed patients, followed by Kilinochchi and Mullaitheevu, and then Mannar. Keep in mind that this study only takes into account patients at the Jaffna Teaching Hospital and excludes data from other clinics/hospitals. Among the newly diagnosed CKD patients 50% were aged 17-49 years, 32% were 50-69, and 18% over 70, with males afflicted more than females.

The WHO found that the typical CKDu patient is a poor male farmer aged 40-70 years, with a family history of kidney disease. Keep in mind that although this is the typical CKDu patient, there are other types of CKD and that in Dr. Surenthirakumar’s sample pool, house-wives were the most affected, followed by farmers, businessmen, and then teachers.

Dr. Surenthirakumar and his team also found that 29% were diagnosed at an early stage, while 70% only at a later stage. This is why regular check-ups are important. Hypertensive patients should get their blood pressure checked by a doctor at least every year (aim for pressure below 140/90) and diabetics should check their Hb A1C at least every 6 months (aim for below 7.0%).  Tests to check for kidney disease are a urine test (looking for excessive protein) and a blood test for your glomerular filtration rate (GFR – checks for a waste product called creatinine from muscle tissue).

Treatment:

Treatment plans depend on what stage of kidney disease you have, besides your other health problems. It includes managing your blood pressure, cholesterol, and blood sugar if they are high, protecting kidney function with certain medications, treating any symptoms (e.g. anemia, bone disorder), and tracking your progress. Treatment can help slow down or stop kidney disease, depending on what stage you are in, how carefully you follow your treatment plan, and what caused your kidney disease. If kidney disease gets worse it can lead to kidney failure, which has no cure.

Dr. Ranga Weerakkody, a consultant nephrologist at the Teaching Hospital, Jaffna, discussed treatments that can replace the work of your kidneys.

Evincing a spirit of reconciliation, he sat through two hours of talks in Tamil, which he does not understand. He apologized for speaking in English and noted that for those who have come through the war, tackling CKD is a minor issue; however, he added that CKD is worse than the war. Appreciating his sentiment, however, I respectfully disagree because CKD is preventable and only affects approximately 10-15% of the population, while the war was out of people’s hands and affected everyone.

Dialysis is offered in Jaffna and Vavuniya within the Northern Province, and kidney transplants only in Colombo and Kandy. Dialysis removes wastes and extra water from your body. In hemodialysis, more commonly used in Sri Lanka, a machine pumps blood out of the body, filters any toxins the kidney could not remove, and then returns the filtered blood back to the body. In kidney transplants, a healthy kidney from a matched donor is placed in your body. Certain tests are done to confirm matching to ensure the body does not reject the transplanted organ.

Although early stages of kidney disease are hard to detect, with regular checkups by your physician and routine tests, it can be caught early and treated. Make sure to eat healthful meals, drink lots of water, and exercise. Remember that Kidney Disease can present in anyone, so regardless of your age, weight, class, or gender make sure you check-in with your doctor regularly – a yearly visit can do no harm.

Mr. Alvapillai SIRI  (Divisional Secretary, Nallur), Dr. T. Saththiyamorthy (Director of the Teaching Hospital, Jaffna) also spoke. And Lion V. Niranjan coordinated the event and gave a vote of thanks.

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Latest comments

  • 8
    2

    Introduce integrated pest managment, minimize or eliminate pesticide application, reduce or eliminate artificial fertilizer application. check the water quality for pesticide residues,chemicals and heavy metals etc.,

    West is using that kind of methods.

    • 8
      1

      So agree Jimmy.

      Btw, we should avoid talking politics and speak to topics that matter.

      Again, I agree with your thoughts.

      Vishva.

    • 4
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      jim softy

      At last I agree with you, on this topic! Ooph a big sigh!!

    • 1
      3

      They are all TNA voters.

  • 12
    1

    Provincial Ministry of Health (NP),

    “To prepare the people in the Northern Province, the Lions’ Club has come forward to raise awareness and has begun a fund to help people. They also organized this public health awareness seminar on CKD at the District Secretariat Auditorium in Nallur on March 15, 2017.”

    Thank you Lions and thank you Dr A.A. Hoole for being the latest Dr Hoole on CT. Always nice to see the next generation.

    What is the strategy of our Provincial Ministry of Health to prevent the increase of Chronic Kidney Disease in the province? To leave it for the Lions?

    I have understood that Chronic Kidney Disease may be connected to the quality of water and various chemicals that we eat and drink. Thus a common strategy of the Provincial Ministries of Health and Agriculture is called for.

  • 15
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    Well written. Informative. Excellent. Recommended reading.

  • 12
    1

    CKDu incidence in Jaffna has been low probably because agriculture and use of fertilizer/pesticides were minimal due to prohibition of agricultural chemicals during the civil war.

    (Agri Chemicals can be used to make bombs, e.g. Oklahoma Bombing by Timothy McVeigh using Ammonium Nitrate and Nitromethane fertilizer truck bomb)

    Rrecent research article by Thushyanthy Mikunthan ( https://scholar.google.com/citations?user=mB0QhzsAAAAJ&hl=en ) and C.S. De Silva highlight the accelerating
    depletion of the limestone groundwater aquifer in Jaffna peninsula. There are two serious concerns that need to be addressed because of this.

    a) As the authors point out, with thousands of people returning to settle in the former war zone, groundwater extraction is bound to increase, resulting in shortages of water supply in the Jaffna peninsula for agriculture and domestic use.

    b) With pesticides and fertilizer runoff seeping into the groundwater the main source of drinking water in the Jaffna peninsula, kidney and other health issues are going to become more common. I think the Chronic Kidney Disease (CKDu) prevalent in Anuradhapura will be be a walk in the park, compared to what is probably in store for the Jaffna dwellers.

    Without dilution, or drinking harvested rain water, or bottled water from the South CKDu is going to increase. The surface wells in Jaffna, have hard water and replenished by rain water run off, taking with them agricultural fertilizer and pesticides. All the right diets etc will have minimal impact.

    Jaffna and other limestone rich areas (e.g Mannar,) badly need water sources that are relatively uncontaminated. e.g the River for Jaffna or the Iranamadu Canal (Mahaweli water).
    http://www.asiantribune.com/node/85645

    Very urgent need, more important than devolution or whatever.

    • 1
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      sbarrkum,

      “Thushyanthy Mikunthan”

      I believe that some of her research has been complained of at UoJ but unfortunately I don’t have the details. Anyway what you take up makes sense.

      “a) As the authors point out, with thousands of people returning to settle in the former war zone, groundwater extraction is bound to increase, resulting in shortages of water supply in the Jaffna peninsula for agriculture and domestic use.”

      When too much(=more than rain water that partly becomes ground water) of the better less salty water is used salty water replaces it. The result is more brackish wells that have water that is too salty for drinking and even many plants like bananas.

      “b) With pesticides and fertilizer runoff seeping into the groundwater the main source of drinking water in the Jaffna peninsula, kidney and other health issues are going to become more common.”

      The less water the higher the concentration of contaminants. This is now happening because of the drought. It was reported in local media last week.

  • 14
    1

    Well written article by Dr AA Hoole.
    Awareness of CKD is very important so is education in preventing the disease.
    I have read a lot about the polluted drinking water from the wells.
    I wonder what had been the outcome of the outcry soon after the end of war regarding the contaminated drinking water in the North .
    The so called rich agricultural lands in the North were contaminated with unhealthy chemicals!!
    Why all the outcries had been silenced??
    Are the effects of the negligence now proves to be the cause of CKD in epidemic level??
    Need an answer.

    Building highways and sky scrapers need to be considered secondary to nations health.

    • 7
      1

      Analyst,

      “I have read a lot about the polluted drinking water from the wells.”

      When I read that Dr. Peranantharajah urged us to drink “just clean, pure water” I wished he had told us where to find it.

      It would be interesting to know how many doctors in Jaffna and rest of the NP have installed Reverse Osmosis filters in their homes.

      • 2
        1

        Every nincompoop going on about clean water going to do this or that , then all goes silent? Why??
        Inefficiency of the professionals and the government ?
        Treating patients when the problem gets to epidemic level is unimaginable.
        Nip it in the bud try to get all the help ., that’s what these do gooders should do.

  • 2
    1

    Time to revisit article and comments
    https://www.colombotelegraph.com/index.php/a-river-for-jaffna/

  • 6
    11

    Has the Tamil separatists and diaspora gone to the UNHRC yet, to claim the GOSL is active in Tamil genocide in the north with kidney diseases?

    • 4
      3

      How can you say it is not? How can you be sure that contamination of soil is not a deliberate act by the military?

      • 2
        1

        There you go mr. Nuwan.

  • 5
    1

    A good piece on the happenings in the North.

    Btw, can someone update on the project to rehabilitate our ancient water tanks.

    Thanks in advance.

    Vishva.

  • 1
    1

    Prevention is better than cure. The preventive action should be for charitable organisations, foreign organisations and entrepreneurs to be approved to sell reverse osmosis treated water at an approved price, based on the well established model of the Navy Engineers.

  • 2
    0

    New generation Hoole has joined CT. So, every 30 years there is a new Hoole. I had a relation Dr Hoole down Inner Flower Road, Colombo 3 in the 1940’s. They are from Manipay. Daughters married Arthur Ratnavel, CCS and Ambassador and Dr Mather. Are they relations of AA Hoole ?

    • 3
      1

      Yes. Mrs. Ratnavale before marriage was Poovathy Hoole, first cousin of Annahl Anbini’s grandfather

  • 3
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    “Dr. Peranantharajah also urged everyone to drink more water, not colored drinks or soda, just clean, pure water.”

    Yes, drinking water regularly throughout the day is a good defense against kidney disease. For example, kidney stones come from the buildup of calcium and other minerals in the kidneys. Obesity will often compound any pre-existing health problems. Exercise will prevent obesity; it is also good for hypertension.

  • 17
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    Sri Lanka’s Chronic Kidney Disease identified in 1992 limited to North Central Region previously is now emerging in other regions such as the Southeastern where hill country water is used for irrigation, in particular rice cultivation. There are two fundamental reasons for restriction of CKDu prevalence to these locations.

    The underlying fundamental reason is our geography and topography. Irrigation water from hill country has very small quantities of fertiliser toxins. Arsenic, cadmium and lead are in fertiliser in very small quantities as impurities.

    One could drink that water and it will not cause CKDu because the dosage is insufficient. But if the water were to be used for rice cultivation rice-water footprint magnifies the effect of toxins in the rice. Rice-water footprint is 2000-5000 litres per kilogram. Theoretically, the whole quantity of every toxin in that volume of water becomes available to the rice. But the rice gives out only about 5 percent. The rest remains in the soil. Perhaps ever since Sri Lanka started using fertiliser in the 1950s, paddy fields that used irrigation water from hill country has been accumulating toxins. But cadmium is the one responsible for CKDu.

    The cause of CKDu is dietary cadmium exposure. It gets in to the body from all the food and water sources. However, the amount in water is insufficient to cause CKDu. Typically the contribution from rice is about 50 percent, vegetables etc about 40-45 percent, and from water 5-10 percent.

    Jaffna does not get irrigation water from hill country, presently. Hence, they are safe. As I understand, there are plans to provide hill country irrigation water to Northern regions. Jaffna must say NO to hill country irrigation water unless it is rendered safe. Otherwise, Jaffna will suffer the same consequences as the unfortunate NCR rural communities who grow rice and vegetables in these toxic soils and fall victim. It can be prevented as Dr Hoole claims.

    Kamal Gammampila PhD, MPhil, DIC

  • 1
    0

    Sri Lanka’s Chronic Kidney Disease identified in 1992 limited to North Central Region previously is now emerging in other regions such as the Southeastern where hill country water is used for irrigation, in particular rice cultivation
    Irrigation water from hill country has very small quantities of fertiliser impurities such as arsenic, cadmium and lead.

    One could drink that water and it will not cause CKDu because the dosage is insufficient. But if the water were to be used for rice cultivation rice-water footprint which is 2000-5000 litres per kilogram magnifies the water-cadmium effect. Theoretically, the whole quantity of every toxin in that volume of water becomes available to the rice. But the rice gives out only about 5 percent. The rest remains in the soil. Perhaps ever since Sri Lanka started using chemical fertiliser in the 1950s, paddy fields that used irrigation water from hill country has been accumulating toxins. But cadmium is the one responsible for CKDu.

    The cause of CKDu is dietary cadmium exposure. It gets in to the body from all the food and water sources. However, the amount in water is insufficient to cause CKDu. Typically, the contribution from rice is about 50 percent, vegetables etc about 40-45 percent, and from water 5-10 percent.

    Jaffna does not get irrigation water from hill country, presently. Hence, they are safe. As I understand, there are plans to provide hill country irrigation water to Northern regions. Jaffna must say NO to hill country irrigation water unless it is rendered safe. Otherwise, Jaffna will suffer the same consequences as the unfortunate NCR rural communities who grow rice and vegetables in these toxic soils and fall victim. It can be prevented as Dr Hoole claims even in NCR.

  • 15
    2

    A most welcome comment from the South, emphasising that we are one country, and that we should be helping one another.

    Eusense has (as usual!) wanted to stir trouble, and Nuwan, too, in trying to counter THAT has strayed in to dangerous territory. Let me hop that any more comments coming in don’t amount to spam. I will leave it to the scientists to sort this one out!

    I know this Kamal Gammampila PhD, MPhil, DIC, and he’s a very serious scholar.

    • 1
      0

      Hi Pannini

      A cursory search for peer reviewed publications by Gammampila did not get any results. Just many youtube presentations and articles in Sri Lankan newspapers.

      Now to Gammanpila’s contention
      Jaffna does not get irrigation water from hill country, presently. Hence, they are safe. As I understand, there are plans to provide hill country irrigation water to Northern regions. Jaffna must say NO to hill country irrigation water unless it is rendered safe

      So
      a) Jaffna has low rainfall stagnant water + pesticides/fertilizer = high concentration of Cadmium and all else.
      b) Hill country has high rainfall + pesticides/fertilizer= low concentration of Cadmium and all else

      Then would not
      Jaffna High concentration+Hill country low concentration= Lower Concentration in Jaffna.

      Flawed science or racism in a science garb/clothes.

    • 2
      2

      SM
      You are a foolish sinhala man. You have still not learnt how Tamil Separatists operate. Imagine, the yet not well understood and unsolved CKD problem of north central province happened in Jaffna first. GOSL will be in ICC by now.

      Who are the “serious” scientists you talk about? What are their backgrounds? What peer reviewed publications do they claim?
      In my mind the only sensible contributor seems to be sbarrkum.

    • 10
      0

      I’ve just got back to Bandarawela, in Uva, (where I was born) after about ten days in the Colombo area.

      I’ve always known that I’m “a foolish sinhala man” as Eusense proclaims.

      As for Dr Gamampila he certainly is a serious-minded guy who was in school with me more than fifty years ago. How valid his Science is, is something that he will now have to demonstrate.

      Few countries have as much rainfall as Sri Lanka, although the Badulla District is considered the Dry Zone of the Hill Country. The Moneragala District is definitely Dry Zone, but these are relative terms. However, I feel that rainfall figures alone shouldn’t fix those terms. There’d be much less evaporation n a “temperate country” than here.

      The Bandarawela area has two further problems. Over the years population has swelled because we are reputed to have one of the best climates in the world. And then about seven or eight years ago, they started this mad “Uma Oya Scheme”. Fertilisers have been used here. Even I’ve been scattering the stuff around fruit plants.

      All of this is collective foolishness. My father (who died in 1963) was pretty knowledgeable about agriculture, but half my family are now foreign citizens, and even of the others, I’m the only guy who had vague fears even forty years ago of water shortages. We don’t harvest rain water any more, we’ve lost the well my father had obtained on a valid permit “half a mile away”. We are paying now for collective irresponsibility.

      We have two good houses with one inhabitant in each. More can’t occupy, because the Water Board sends water only once in 15 days. But that is sent for about 30 hours; those who have invested in 20,000
      liters of storage capacity (PVC tanks – how safe?) can manage, but is it the solution for everyone to do so?

      I have little idea how the poor are going to manage – unless we become wiser and straighten out our priorities.

      • 7
        0

        Sinhala_Man,

        I was very surprised to read your facts on water! Thank you. You have shown that there are major problems in other parts of the country that we (or I) did not know about before.

        “More can’t occupy, because the Water Board sends water only once in 15 days.”

        A pipe from a huge tank or bowser?

        “But that is sent for about 30 hours; those who have invested in 20,000 liters of storage capacity (PVC tanks – how safe?) can manage, but is it the solution for everyone to do so?”

        PVC and other plastics are NOT safe. Is the quality of the water known?

        How about a tube well or rain water harvesting?

        “I have little idea how the poor are going to manage – unless we become wiser and straighten out our priorities.”

        In rural Jaffna the poor and even the not very poor use plastic containers (especially the yellow veg oil containers) to fetch drinking water of dubious quality from far away.

      • 5
        0

        Thanks, Lone Wolf, for understanding that there are problems everywhere, and for appreciating that guys like me often don’t know what to do.

        The water comes through pvc pipes, and is metered. I can, and do, run down to Colombo, if I run short of water. A whole family with schooling kids etc, can’t do this. They have to purchase a bowser of water at around Rs 2,000/=.

        We are increasingly dependent on plastics. Chemistry never appealed to me as a school boy, there seemed to be so much to memorise. However, I now look at the re-cycling numbers at least:

        http://ecovillagegreen.com/903/what-do-the-plastic-recycling-numbers-mean/

        There is an array of such blogs. It is unfortunately in the interest of industry to keep manufacturing plastic containers, so they will NOT encourage re-cycling. When they take away 5 kilos of plastics, they give you a basin in exchange – with no re-cycling number – perhaps they make it with a mix! Still, I believe it’s better to hand them over (never mind the reward of the basin!) than burn it all. It is safest to stick to glass. To recycle the jam jar itself the government should insist on ONE design only – for almost all time! There are other ways of being creative!

        Another growing source of pollution: electronic waste.

        We train too many accountants, too few economists. “Big business” dictates too much.

        PVC tanks – with us to stay, I fear. Quality of the water? Trust the Water Board! But let me say this: I do have two “open non-plastic tanks”, with little stream fish brought years ago by village kids whom I paid (we had many little rivulets when we were kids here – now mostly gone). I was told that these fish need no food, partly true of one, where leaves fall in! The other: a hundred rupees of fish food I find lasts a year. Since the fish live and breed the water can’t have deadly toxins.

        Rain water harvesting is a must – almost not done! Someone once told me that gutters around houses are not allowed because they allow mosquitoes to breed. Balancing these menaces is the problem.

        What we have lost is a sense of “community living”. We need wise “Elders”, not politicians.

        Tube wells – being thought of now, but again, how sustainable? Little planning for great, great grandchildren!

        One has to come back to the need to STOP population growth SOMEHOW: through education would be best.

        • 1
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          “Development” has usually been a gradual process for most families. My Belgian neighbour tells me that after the Second World War (at the very end of which he was born), Europe was so badly off that they had no luxuries like “sports”.

          So, as a kid, I remember how we had no electricity, and we mainly harvested rain water. Drinking water was fetched in metal buckets from a neighbour who had invested in a Diesel generator, which pumped water up the steep hill.

          With the coming of electricity my father, who had prepared himself for that development by obtaining a water permit, installed an electric pump. However, with the coming of State supplied water, the pipe line was not maintained. Squatting on public land became common because there was less respect for laws, but ALSO there was no planning for population expansion and no sale of state land in a disciplined fashion. So, the pipe-line was built upon, and I guess our family has lost that “grass-rootedness” which is so necessary for us to maintain a “sense of community”.

          Rain water harvesting requires discipline; with relative prosperity and globalisation (I mean half of all English-speaking families have now migrated – never to return for permanent residence), we lose respect for old-fashioned ways. You do know, don’t you, that those little fish (guppies) gobble up mosquito larvae.

          At this moment the Uma Oya Project dominates most public discussion:

          http://www.dailymirror.lk/article/Uma-Oya-Development-Project-Multi-purpose-or-multi-destructive–121570.html

          but I’m sure that most families that “belong more to the area” may know better than ours, what has to be quietly done to get more water! But really, we can’t “manufacture” water. There just isn’t enough.

          For our area what they say is that the three inch pipe bringing water to our area from the main reservoir above the railway station has to be replaced by a six inch pipe (which will bring FOUR times as much water). Right now, they tell me, even it the main reservoir has water, the amount that can be sent this way is fixed by that 3 inch pipe. These local problems can sometimes be very difficult for others to understand.

          The crux of the matter is that WE are the problem. We expect governments to supply everything. We, as a country, have allowed socialism to become “centralisation”.

          Tube wells: won’t they exhaust the “water table”? That may apply everywhere. Here we have the Uma Oya folly.

          Over-population here has other reasons, apart from the “salubrious climate”!

      • 2
        0

        Sinhala_Man,

        “We don’t harvest rain water any more, we’ve lost the well my father had obtained on a valid permit “half a mile away”.”

        What happened to the well?

        Where did water come from before the PVC pipes? The well far away?

        Is there no water for a better Water Board service? They should be able to give you information on the water quality.

        Do other houses have tube or open wells without problems?

        I think that rain water harvesting needs an investment of 60,000 but of course depends on size. Keep gutters clean and close the tank=no mosquitoes. Some built in Jaffna with USAID and Indian funding.

        Tube wells maybe 15,000 in Jaffna now.

        The ponds in my area are almost empty.

  • 1
    0

    “Dr. V.G. Rajeev (Regional Epidemiologist), standing in for Dr. Nanthakumar, Regional Director of Health Services, pointed out that deaths caused by non-communicable diseases (like heart disease, diabetes, and kidney disease) now surpass those by other non-communicable diseases (like dengue and malaria).”

    Interesting to note, that the first group are ‘Development Diseases’ brought about by lifestyle, and diet changes produced by the economist’s notion of ‘development’. The second is brought about by ecosystem changes produced by human activity that create the conditions that allow vectors to move into the population.

    Looks like the developers are doing a better job than the parasites of nature when it comes to negatively impacting the quality of our lives

    • 1
      0

      Ranil,

      Methinks you must have meant to categorise dengue and malaria as “communicable diseases”.

      Yes, we’ve got to reconsider notions of “development”.

  • 8
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    Dear all,

    Here is an idea of how to solve these serious problems following the culture and traditions of our province. The Honorable Ministers and leading government servants of the Provincial Ministries of Agriculture and Health together with the heavy weight experts from the relevant steering committees of the said ministries should form a joint task force. This task force of a minimum of 100 eminent persons of respected Jaffna pedigree should be sent abroad to discuss different solutions with leading Tamil experts of respected Jaffna pedigree in Diaspora.

    All expenses should be paid by the NPC and at least but no more than 1 (one) woman should be included in the task force provided a female volunteers and is able to type the minutes.

    As is well known Canada has plenty of water, snow and ice and many Tamils. Since many members of the task force already have visited Toronto the “Water and Health for Northern Province Conference” should be organized in Vancouver.

    The goal of the conference is to find out how Diaspora Tamils can finance a permanent solution to various problems related to kidneys and water in the province. It is an established fact that only Diaspora Tamils can help us with any and all problem we have. The rest of the world is against us!

    The PPD (Private Public Diaspora) initiatives should include creating massive dialysis centers in remote private rural hospitals that would charge a fee that looks reasonable for a professional working in Canada. Another PPD initiative is to convert Delft island into a huge Reverse Osmosis oasis from where low cost water can be pumped to the main land. On the main land the water will be distributed in three wheelers in traditional clay pots to all the families of the province. Using clay pots and three wheelers will create employment for many. The price of the water will be lower than the price of premium imported mineral water from France. The clay pots will have a deposit and can be refilled at least 99 times. It is important to create only sustainable PPD projects.

    As a temporary solution there should be a resolution from the NPC declaring that all our water in the province is safe enough to be consumed and all health problems related to kidneys are caused by unknown factors that are beyond our control. The resolution should include a call for all Tamils living outside of the province to send bottled water for friends and family. The water should be sent in BPA free plastic containers.

    • 9
      1

      Dear Lone Wolf,

      You say, ” The rest of the world is against us!” and so adopt the strategies used by Jonathan Swift here:

      http://canningrbrhs.weebly.com/uploads/9/1/9/1/9191643/a_modest_proposal.pdf

      There are many presentations of the text of the “Modest Proposal” on the Internet: this seems to be pretty well illustrated – scroll down a bit.

      Seriously, though, Kamal Gammampila PhD, MPhil, DIC (no relation of Udaya Gamanpila) appears to have written recently on this subject – and in commenting here on CT has given sound advice for Jafna:

      http://www.island.lk/index.php?page_cat=article-details&page=article-details&code_title=162127

      • 5
        0

        Sinhala_Man,

        Thank you for the links. There is a wealth of knowledge on water problems but very little political will in the North.

        Somebody has made RTI requests to all five NPC ministers about their traveling expenses. Two including the Provincial Minister of Health have sent the information. I took up the “conference traveling” in my comment. I have found a link only in Tamil so that will not post it. Nice to see RTI action in Jaffna.

  • 2
    0

    I think that kidney disease is already rife in Polonnaruwa and Anuradhapura. At one time the Chinese government was going to build a hospital there specifically for this problem. I don’t know whether it was built or not.

    http://www.news.lk/news/business/item/9568-china-to-build-a-hospital-in-polonnaruwa-for-kidney-patients

  • 2
    0

    It appears CKDu is primarily caused by contaminated water.

    Which ever want you want to talk (spin it) about Jaffna water is contaminated and becoming more so.
    CKDu or no CKDu, the water of Jaffna is contaminated.

    Isnt clean drinking water a Fundamental Right.

    Notice, non of usual people who shout (scream/vociferous) about Tamil Fundamental Rights are silent.

    Is that because getting clean drinking water to Tamil people in the north does not help the political talk (narrative) of “genocide” and “marginalized” Tamils.

    Wigneswaran and TNA to serve their own political agendas are ready to sacrifice current and future generations of Tamils to ill health and low IQ because they do not have clean drinking water.

    Disclosure: I am not an academic living in an urban area. I live in the dry zone of SL with hard water from dug or deep wells. However, this area is blessed. It has two reservoirs fed by rivers from the hill country. The villagers and I drink water from dug well near these reservoirs (collected in 25L cans and brought to the house by three wheeler. LKR 50/can).

    No CKDu patients that I know or heard (sinhala_man please note).

    • 1
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      sbarrkum,

      “The villagers and I drink water from dug well near these reservoirs (collected in 25L cans and brought to the house by three wheeler. LKR 50/can).”

      Make sure that the cans are safe to use. Plastic very rarely is. Stainless steel.

      • 1
        0

        Lone Wolf.

        Costs: Plastic vs Stainless Steel. I cant afford it,

        One of the poorest villages historically. Now getting ahead because of a fancy road built by the last govt.

        A renovated old reservoir (Achimalai) filled in by hill country water/river. It will provide clean Drinking water (huge water purification plant) to a minor/major town 30km south.

        I could give more details, but why tell all for those seated in another country.

        Another point,
        I would guess most other commentors live out of SL.
        I am a Sri Lankan citizen (lived in the uS legally for 25 years, Student Visa and 3 H1B visa).

        I travel by bus. Dont own a car.

        There have been times I did not have money to eat.
        No comparison to poor villagers.

        All I had to do was get off my pride, call a friend and would have money to eat.

        One has to be hungry to understand.

  • 0
    0

    “Wigneswaran and TNA to serve their own political agendas are ready to sacrifice current and future generations of Tamils….”

    Thanks.
    Good to hear it from another sane voice here.

  • 1
    0

    According to Dr. Palitha Bandara, the top health official in the North Central Province, “since farm chemicals are the suspected source of the toxic metals, the government should improve measures to test fertilizers and pesticides imported into the country — to make sure they are safe. Many fertilizers, he says, come from China. “We don’t know what types of chemical ingredients, elements, are there in the fertilizers,” he said.”

    This may be the source of the problem, in my opinion. In China, when it comes to industrial standards, quality control is very poor. That is why there is so much pollution there, to the extent that people in Beijing wear face masks. I have read stories about dog food and toys exported to the States containing dangerous chemicals. So it is logical to infer that these pesticides imported from China contain unusually HIGH concentrations of dangerous chemicals, such as cadmium and arsenic. It is not necessarily the FERTILIZER that is the issue here, it is the fertilizer imported from China. This is not a difficult problem to solve. A chemist can easily find the concentrations of chemicals in a can of arsenic. It is then up to the Government to ban imports from such countries, if necessary.

    • 1
      1

      Lester
      Watch your words !! You might be Gingkopooped by the Chinese and the Yumplanas!!!

      • 0
        0

        It is no joke. See this notice from the American Food and Drug Administration (FDA):

        COMPLAINTS

        “As of December 31, 2015, FDA has received approximately 5,200 complaints of illnesses associated with consumption of chicken, duck, or sweet potato jerky treats, many of which involve products imported from China, which produces much of the jerky pet treats on the market. The reports involve more than 6,200 dogs, 26 cats, three people, and include more than 1,140 canine deaths.”

        Kidney issues were also not uncommon:

        “Test results on affected dogs have shown kidney problems. The kidney problems are often similar to Fanconi disease. (Fanconi disease is an inherited disease in which electrolytes and nutrients are lost in urine.) Although many affected dogs can be treated and get well, some jerky treat-related deaths have been reported.

        “In 2007, affected dogs were seen in Australia and the United States. That original outbreak ended in 2009 after all the affected treats had been pulled from the market. However, similar cases have been seen since then in the United States and Canada. Unfortunately, the definitive cause of the problem is still unknown.”

        Bottom line: these chemicals are deadly. If the Sri Lankan Government does not take action to ban these (Chinese) imports, other illnesses besides kidney disease will eventually appear. You also have the potential for an epidemic (mass outbreak of disease), which will be very costly to deal with.

        • 0
          0

          Lester,

          “If the Sri Lankan Government does not take action to ban these (Chinese) imports, other illnesses besides kidney disease will eventually appear.”

          No ban but a Free Trade Agreement.

  • 4
    0

    A.A. Hoole,
    An excellent work and need of the hour. Your article carried more information which were not divulged before in regard to CKD. I do not know you may know an educational programme is going on in the schools to some awareness among school children about CKD. My wife, a teacher at AK/ Al-Muneera Girls High School, Addalaichenai is assigned a project about this. I had highly recommended your excellent article to be used for the school children. We want doctors like you.

    Dr. A.M.Jazeel PhD (Education)

    • 1
      0

      Dr Jazeel,

      “I do not know you may know an educational programme is going on in the schools to some awareness among school children about CKD.”

      Can you please ask your wife who is behind the awareness campaign and post the answer here.

      Thank you.

      • 2
        0

        Dear Lone Wolf,
        Thank you for your positive comments. I asked my wife. She told me it is a “sustainable school development project -2017” implemented by the ministry of education in selected schools. Under this projects, several sustainable projects are implemented. One such project is CKD. The teachers incharge for the project are tasked to make awareness about CDK. It is very useful project for the students.

        Dr. A.M. Jazeel

        • 1
          0

          Dr Jazeel,

          Thank you for the update.

  • 2
    0

    Of course while the nation is dying of incurable diseases which of course can be prevented or treated our Parliamentarians are wasting every CENT OUR CENTS ON THEIR HIGH POWERED VEHICLES, PERMITS AND LUXURY LIFE OF EXCESSES.??

    HURRAY HENRYS THE THICK HEADED OFFSPRINGS OF THESE PARLIAMENTARIANS HAVE NOTHING TO DO WITH THE STATE OF THE NATION BUT ENJOY CLUBBING!!!
    Great Ape SinhalE Lanka .

    What about the Milk Powder Formula for babies?? 2 years ago the milk powder used for babies , biscuit making ect were found to be contained/ contaminated Melamine, yes Melamine!!
    The rich and prosperous Chinese sent their contacts to UK to buy in Bulk the quality checked SMA tins from the Boots Chemists .

    How about that , while SL was using the same kind of powder to make our own brands of biscuits and hoppers.
    All these were hushed up !! Bad for our Businesses!! Yes! Bad for our Business chiefs.
    Are our children and adults being poisoned by these profit making scandals??
    Food for thought!!.

    • 1
      0

      Eating out is a fashion in Srilanka among the well to do.
      Actually these people should pause for a few minutes before bundling the kids and wife in their Suvvs to consume delicious lunch or dinner.
      Do they know what and where the ingredients came from to produce that delicious treat???
      You can be at least 90% sure home made cookies , cakes, and delicious homemade meals are much more healthier for your family.
      It’s all a vicious circle to know how the world has changed and our habits have changed,
      We all know the old adage ” you are what you eat”.

  • 1
    3

    I just remembered.

    Jeevan Hoole made a legal change in the uS to claim he was black (African-American).

    So his children got into uS universities based on Affirmative Action.

    Really, Jeevan. You are the real suck up artist.

    ================================

    In case you have forgotten, the reference to Asavameda Puja in your book “Exile Returned” has no credits. It was an email exchange on soc.culture.sri lankan. Still archived on google.

    The original article was by a Meenan Vishnu. I just copied and pasted. Did some cross check on the Rig Veda.

    ================================

    Jeevan Hoole know you wont reply to this.
    The perfect real suck up artist.

    • 7
      0

      Barr-Kumarakulasinghe:

      1) I am replying to you although there is no relevance to the article and what you say is even slanderous. I always thought well of you as a person without hangups and from a distinguihed family “connected” to me. I hope that was not too wrong of me to have thought so well of you. Perhaps your once liberal mind after living on temporary visas in the US for 25 years without knowing when the next extension would be refused has disturbed your balance.

      2) I am not aware of any provision for changing my race. I am what I am. In any case I have not been through any legal process to change my race as you claim.

      I have publicly argued that the choices the US government forms give us to categorize our race are inadequate: Caucasian, Black, Asian/Pacific Islander, Hispanic. This is because we South Asians are at once Caucasian, Black and Asian.

      In any case my daughter did not get into any university under Affirmative Action although our son and one daughter explained in their college applications that the tick boxes are inadequate and why — such ways of getting noticed by admissions counselors always help. However, they have always been upfront about our “race” if we have any.

      You sound like some of my South Asian friends who were against Obama assuming that he got into Harvard under Affirmative Action. Even if he did, he is not diminished in my mind in any way while racists who say this of him are. Affirmative Action is a good thing for historically discriminated people.

      3) You are wrong about my not giving due credit on Asvamedha–yajna in my book The Exile Returned. Please see page 110, footnote 225: Majumdar, 1960; p. 83

      Besides, I would never quote an unreliable source from amateurish internet debates, nor would I fail to credit a source I am using.

      • 0
        0

        Now to the H1B work Visa (I did not want to sell my birthright for mess of pottage like Esau)

        Perhaps your once liberal mind after living on temporary visas in the US for 25 years without knowing when the next extension would be refused has disturbed your balance.

        I am secure/confident/unafraid than many, bcos no children. Anyway happiness is a state of mind. Also no qualms in taking pentobarbital/Nembutal if I think I am going to be a burden to others.

        There are some of us (as far as I know only me) who dont want to to reject the country that gave free university Education and become a citizen/PR of another country. The first two H1B (late 90’s, early 2000s), my employers pressed me to get a Green Card. H1Bs are too much paperwork. Left the first H1B in 2003 and came back to SL. Went thru a divorce and walked away from all assets. Then got an invitation to do more work in the uS. Left in 2010. Then my SO/women friend wanted me to come back for few years to the uS. So back to the uS in 2012. Hanged on for over a year. Health deteriorated (severely diabetic) and back to SL. Now healthy (low sugar, no medications) despite smoking and drinking beer/alcohol regularly. The sun and hard physical work is the best medicine.

        The long winded story is about the benefits of living in SL villages. Loss of income and “getting ahead” but better health sans medication.
        Long distance relationship: SO/women friend and I now spend one month in SL and uS. The long term plan is when we are 62 (both 59 now) and social security kicks in she will spend six months in SL.

      • 0
        0

        Dont get me wrong, I love the uS and its people (not its govt policies). Crossed the country three times (NYC to west) in an old car and tent and camping. Many times North South, Toronto, Montreal to Lousiana, Florida, El Paso. Pristine waterfalls, with almost no people 1.5hrs from NYC. The best places to windsurf/kitesurf in NYC/Long Island. That said SL has most of this in less travel time.

        The idea of rejecting Sri Lankan Citizenship is like a divorce and marrying a younger wife (Europe/uS). Then as people get older they long for the comfort and familiarity of the old wife. They start doing extended visits, some remarry the old wife (Dual Citizenship). Its the rare person who completely cuts of ties to the old wife, i.e. never wishes to come back to SL. However cant sever ties with the young wife. She is a piece of arm candy that opens doors to exclusive clubs (travel). She also can be a bitch if you try to divorce her. Try exiting your uS citizenship. You will be taxed on 50% of assets.

        The justifications for these mutiple reationships (passports) range from Safety, Getting Ahead, Easy Travel, chidrens education. Each to his own I say.

        Finally, Some want/desire recognition in their own community. Specially in the form of honors, positions. When these become elusive, bitterness ensures and lashing out at the rest.

    • 4
      0

      “legal change in the uS to claim he was black (African-American).”

      No educated person will write such nonsense. Has somebody hacked sbarrkum’s email address?

      How do you fake the African-American hair at interviews? How do you speak Afro at the College selection interview? How do you write your personal life essay for the application pretending to be African or even American?

      Are you for real man? Jealous gossip from some low grade university academics who compete with Professor Hoole is sometimes like this.

      Indian children applying for engineering face discrimination and have a cut off point way above other communities here. It is called reverse discrimination. I have studied in the US. I know some of Professor Hoole’s children entered engineering. I have met them at functions and they are very nice and smart children.

      I like this article very much Miss. Hoole. It is useful to know. My mother and brothers live in Jaffna and I am concerned. Best wishes for a bright future.

    • 1
      0

      First Apologies for

      a) I have publicly argued that the choices the US government forms give us to categorize our race are inadequate:. Recall an online conversation and remembered INCORRECTLY that I have not been through any legal process to change my race.

      b) wrong about my not giving due credit on . My copy (yes I bought it) has been long gone. Lent/borrowed in early 2000s. So was going by memory, not the best for reference.

      The reason for this angst were the comments of
      a) “suck up” re the guy who carries your bag.
      b) The “moral Tamils” were entrapped by the “loose morals of women of Katubedda”.

      Like I mentioned before, my family and yours sucked up to the colonials. I am sure they “carried bags” for the colonial administrators and missionaries.
      You also know very well upper class (caste) Tamil slept/had concubines with the poorer classes/castes. In Jaffna, with the power hierarchy, the poor had no recourse to convert a “relationship” to a marriage. The Jaffna Tamils without the family clout in the South would be “trapped” into marraige in Katubedda.

  • 0
    0

    This comment was removed by a moderator because it didn’t abide by our Comment policy.For more detail see our Comment policy https://www.colombotelegraph.com/index.php/comments-policy-2/

  • 1
    0

    The International Water management Institute did a very good literature review of this problem and published a working paper. (#158)
    “Review of Literature on Chronic Kidney Disease of Unknown Etiology (CKDu) in Sri Lanka”

    http://www.iwmi.cgiar.org/publications/iwmi-working-papers/iwmi-working-paper-158/

    With regard to CkDu in Sri Lanka it has been difficult to prove that the heavy metal Cadmium is the causal factor.
    I had corresponded with Ranjith Mulleriyawa who was active in this area. He indicated the following in an email exchange:
    While acknowledging that Cd is a well known Nephrotoxin, our Nephrologists claim that Kidney damage in CKDu patients is very different from Cadmium induced Nephropathy.
    Dr.Gammampila needs to challenge the Nephrologists if wants move forward with his claim.

    IWMI working paper is hypothesizing that fluoride in combination with other dissolved minerals such as Ca, Na and possibly Mg could be the cause. Prof. Chandra Dharmawardene came up with the Hofmeister series theory to explain this phenomenon. Still nothing is certain.

  • 7
    0

    Re: Berners Lee comment

    Indeed I am challenging these claims.
    I am recently submitted my re-analysis of the WHO/MOH study data to the NSF with the request it be subjected to review by national or international appropriately qualified academics. I conclude cadmium as the cause with the proviso that all the other bio-incompatible agents in the food chain including drinking water should be investigated for their contributions. I also claim that whether other agents were there or not the cadmium levels in urine is sufficient to account for CKDu all by itself.

    My analysis is based primarily on the currently available toxicokinetic models and critical reference levels of the Codex Alimentarius commission of the UN. CKDu prevalence is more than twice as much as declared by the WHO/MOH study.

  • 3
    0

    It is timely to raise awareness of the dangers of CKD to Sri Lanka’s population and this article is very useful in that regard. Also, as implied, in respect of patient care, Haemodialysis is logistically challenging (particularly for rural folk) and Kidney transplant is complex and necessitates life-time medication which is not without serious side effects. CKD is well known as a silent killer, and the best thing is of course, to avoid it by adopting the lifestyle modifications so well articulated by Dr. Peranantharajah.

    With regard to CKDu however, the differentiation must be drawn that it is mostly NOT within the patient’s control to avoid, as the causative agent is usually something insidious, usually ingested via food or water; or inhaled via smoking. As well, the damage to the kidneys in CKDu occurs in a different location to that caused by conventional CKD.

    The inclusion of ‘Jaffna’ in the title is very interesting, for current statistics will demonstrate that the northern province suffers far less from CKDu than the Rajarata or other endemic region such as Badulla. The question is why?

    The answer may lie in the unintended consequences of two key national initiatives, namely (i) the “green revolution” which encouraged the import and generous subsidies of agro-chemicals and fertilisers and (ii) the Mahaweli diversion scheme, which brings water from the hill country, also found to contain fertiliser residue from applications there. This may explain why the Rajarata region has become a hot-spot for CKDu, and supported by the recent WHO study which can be referred to here: https://bmcnephrol.biomedcentral.com/articles/10.1186/1471-2369-14-180 – This report refers to Cadmium as the potential causative agent; this being a well-known impurity in phosphate fertilisers.

    • 3
      0

      Karl Uduman,

      Greatly appreciate your insightful and well researched explanation on the matter. Please write a full article to Colombo Telegraph on your findings and efforts towards combating this problem. It will help with advocacy efforts.

  • 2
    0

    Dear CT Ed:

    Unfortunately the comment was truncated and needs to be expanded for completeness’ sake.

    The North of the country was spared this disease because (a) fertiliser movements were banned during the past three decades or so, as some fertilisers had potential to be “weaponised” and (b) Mahaweli waters don’t go as far as this region.

    If shipments of fertiliser to the north have now resumed, then stringent checks should be made to identify the levels of cadmium in TSP and carefully control its use there.

    Additional spot checks on rice and other food crops should be made, in order to ensure that consumption levels of contaminants such as cadmium are maintained to within the internationally published standards. This is a matter for health scientists and the authorities to manage.

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