By Amarasiri de Silva –
The disease picture in Sri Lanka is fast changing. An increase in sedentary occupations, less physical exercise and new dietary practices are seen as factors that have contributed to an increase in cardiovascular diseases, diabetes and obesity, especially in urban areas. Ecological changes and the use of agrochemicals have led to asthma, various cancers, and kidney disease in rural areas. These non-communicable diseases [i.e. cardiovascular, etc. as well as asthma, etc.] have become the major disease category in the country over recent decades. The latest addition to the list is Chronic Kidney Disease with an unknown causation [aetiology] or CKDu.
CKDu is something new, and it is spreading in many tropical countries. The production and development [pathogenesis] of this type of kidney disease is unknown and is not linked to traditional factors such as hypertension and diabetes. One explanation for the emergence and spread of CKDu is that it is due to global warming [that exacerbates dehydration, which is linked to kidney failures and stone disease]. In Sri Lanka, it has been suggested that the cause is ecological change brought about by the green revolution, which has seen the introduction of many new agricultural practices, such as the application of pesticides and chemical fertilizers, and new water management and irrigation systems. Some have even postulated that the chemical and biological warfare that occurred during the secessionist war fought by the LTTE against Government forces introduced deadly chemicals into the ecosystem of the northern region. Because of the difficulties involved in identifying of the cause of the disease, it has become known as CKDu, or CKD with unknown aetiology or ‘u’.
CKDu seems to have been first identified in the 1980s in a hospital in Anuradhapura. Records show that the first death of a patient identified as having the disease occurred in 1993. Since then, the disease has been reported in many parts of the northern regions of Sri Lanka, and has spread into the districts of Badulla and Hambantota. In 2010, there were 20,336 confirmed CKDu patients in Sri Lanka (MOH data 2010). The largest proportion of these patients was reported from Anuradhapura District (8,044 cases or 39.5%), while Badulla District (4,656 or 22.9%), Mulaitive and Vavuniya Districts (1,287 or 6.3%), Kurunegala District (1,251 or 6.1%) and Ampara District (977 or 4.8%) recorded the second, third, fourth, and fifth highest numbers of patients respectively. CKDu has become the most researched and highly debated disease category in contemporary Sri Lanka.
In 2011, the prevalence of CKDu in the affected districts in Sri Lanka was about 2–3% of the population aged over 18(Chandrajith et al 2011). This had increased to 15.3% in 2012 when the WHO conducted its study in the three districts of Badulla, Polonnaruwa and Anuradhapura. This would suggest that, taking Anuradhapura alone with a total population of 856,232 (Census and Statistics 2011), the CKDu positive population has increased from around 20,000 in 2011 to over 130,000 in 2012 a more than sixfold increase over one year. If the incidence of the disease as determined by eminent scientists is accepted, then this not only points to an astonishing increase in the CKDu patient population in the affected districts over one year, but also suggests a phenomenon which can be regarded as a disaster; particularly so when the scientists convincingly show that the disease is spreading into other districts as well and the death toll due to the disease surpasses that in the recent secessionist war. In a recent study Bandarage (2013) states that ‘Between 1990 and 2007, hospital admissions due to all diseases of the genitourinary system in Sri Lanka doubled with hospital deaths due to such diseases rising from 2.6 to 9.1 per 100,000 people’. So far, in Anuradhapura, informal statistics suggest that the total number of confirmed CKDu patients is around 20,000. Dr. Weeraratne’s feature in Island (6 January, 2014) shows that the number of CKDu patients registered at MOH offices in CKDu endemic areas could be as high as 25,000. This indicates that there is a large hidden population with CKDu. The annual figure of deaths recorded due to CKDu is as high as 1,400 in the country (Athureliya et al 2009). Close to 5% of the country’s annual health budget is spent on the disease management of CKDu patients.
As early detection and treatment is regarded the best approach for containing the disease, the hidden nature of so much of the affected population poses a challenge for the Health Department and for health professionals: how are these unidentified sufferers to be attracted to hospitals and clinics for treatment? CKDu, like many chronic diseases, is often stigmatized, one of the reasons why people in affected districts evade hospital treatment, even after they have been identified as CKDu positive by blood screening surveys in villages. The fact that people avoid hospitals for treatment has a lot to do with the procedures adopted for carrying out and conveying the results of blood screening. Many regard the blood surveys as a means to ‘label’ CKDu patients in front other villagers. As has been successfully done in reproductive health, a euphemism for family planning, inventing a more culturally acceptable expression for CKDu would increase people’s participation in clinics. The most important thing to do here is to redesign the public health approach to CKDu, and make it a culturally sensitive programme that addresses factors such as the social stigma attaching to the disease. Containing this disease cannot be achieved through biomedical research and public health procedures alone, because, as has been clearly shown, the onset of the disease has to do with what people eat and drink and how they behave. People’s cultural response to CKDu should be well understood before any programme is developed to contain the disease; and the findings from such studies should be utilized for programme development. As far as I understand, there has been no attempt on the part of the Government or the Health Department to forge the necessary links between biomedical research and research in the social sciences in order to develop a comprehensive programme to address this disease.
The most recent initiative has been the World Health Organization (WHO) research programme, partly funded by the National Science Foundation of Sri Lanka (NSF), with the leadership and support of the President, the Minister of Health and the Minister of Finance. The final report of this was made public only in English last April following a long-drawn-out lobbying process by interest groups. It is not available on the Ministry of Health website, nor has it been translated into vernacular languages for ordinary people to read. Although it should have been prominently displayed on the Ministry’s website, to the dismay of many, it is hidden away on the Health Education Bureau’s website, where it is difficult to locate.
The findings of the WHO research have now been published in the form of an article (Jayatilake et al 2013) which is accessible online. Most important of the findings are: a) the age standardized prevalence of CKDu was 12.9% in males and 16.9% in females indicating that females form the majority of the CKDu affected population; b) the risk of getting CKDu increases with age particularly in farmers involved in chena cultivation, but this effect is less marked among males engaged in paddy cultivation; c) the mean cadmium concentration in the urine of CKDu patients was significantly higher than in the control population; d) urine cadmium and arsenic concentrations in individuals with CKDu were at levels known to cause kidney damage; and e) food items from the endemic area contained cadmium and lead at concentrations in excess of reference levels. The WHO final report (2012) states that co-exposure of people to arsenic is likely to aggravate the effect of cadmium on the kidney making the changes more pronounced than exposure to Cd alone.
The article concluded that the ‘results indicate chronic exposure of people in the endemic area to low levels of cadmium through the food chain and also to pesticides. Significantly higher urinary excretion of cadmium in individuals with CKDu, and the dose–effect relationship between urine cadmium concentration and CKDu stages suggest that cadmium exposure is a risk factor for the pathogenesis of CKDu’ (Jayatilake et al 2013).
The WHO (2012) finding that females form the majority of the CKDu affected population contradicts earlier reports of the WHO (2008), which identified males as the majority of patients. Having a female CKDu patient in the family, especially if it is the mother, can have serious implications for the family, its livelihood, and the upbringing of children, since families in rural Sri Lanka are largely mother-centred. The finding that people engaged in chena cultivation have a greater risk of getting the disease implies that the disease has hit the indigent populations in the agricultural sector in the remote dry zones. The most conclusive and revealing finding of the report is the identification of cadmium as the pathogenesis of CKDu. Until the WHO scientists’ joint effort of singling out cadmium as the factor causing the disease, the aetiology of CKDu has been a very controversial subject. It is now high time to do away with these debates and further research on the aetiology of CKDu, and focus instead on the findings of the WHO report and other research studies, in order to come to an understanding that multiple factors have contributed towards the genesis of the disease, and that these may include different toxic metals. Let the disease may be named as Rajarata Kidney Disease or Agricultural Kidney Disease, and do away with the ‘u’ or the unknown part of the disease abbreviation. The biomedical scientists who worked on the WHO research project have come to a consensus that the disease is caused by heavy metals. However, this understanding is not sufficient. It is similar to saying that tuberculosis is due to Tobacco bacillus, or the Great Fire of London – the conflagration that that swept through the central parts of London in 1666 – was due to a matchstick or a spark from a baker’s oven. Knowing that it is cadmium that has caused the disease, the crucial question now is how did this heavy metal find its way into the bodies of those affected. So far, this question has not been addressed adequately. Cadmium can be absorbed into the human body when pesticides are sprayed and fertilizers are used in paddy fields and chena cultivation, or through the consumption of contaminated food or water (Bandara 2010). It is clear that the most likely associated causes of the disease are associated with human behaviour.
The time is now ripe for the development of a well-coordinated programme to contain the disease by changing people’s behaviour, agricultural practices, Government policies, and the use of fertilizer and pesticides. So far there is no sign that the Ministry of Health has even thought about any such programme. It is important that the development of such a programme should seek to incorporate public opinion as well as seeking the views of scientists. It is quite clear that any such programme should entail a three-pronged approach. First is the curative and rehabilitative elements: the curative programme should be run by the doctors in clinics and hospitals targeted at CKDu patients; and psychologists, social workers, counsellors and community organizations should play a key role in rehabilitation. The second prong is a preventative programme. Unlike in many other diseases, people’s behaviour plays a significant role in the genesis of CKDu. Changing behaviour requires changes in attitudes, knowledge and value orientation, which is again an activity for the doctors and paramedics as the patients’ first point of contact, while health educators, social scientists, social workers, community-level officers at the DS offices and community organizations have a big role to play in educating non-patients in the districts. The programmes can be organized and monitored through the DS offices and MOH offices in the area. The third prong is the research component: both biomedical and social science research are needed to monitor the outcomes of the disease and to pinpoint its pathogenesis. It is also important to examine how the emissions of heavy metals are regulated in waste incinerators, another possible source of contamination. Perhaps universities, the NSF and similar institutions can orchestrate the research as it is important to analyze the trajectory of the disease, and explore its social, economic and political implications.
The most important issue, however, is what steps the government has taken or proposes to take to address the recommendations implicit in the WHO report. The most important among these is the finding that the disease is caused by cadmium and arsenic. Arsenic as the cause was identified earlier as well (Jayasekera et al 2013). Given that heavy metals are introduced into the area through pesticides and fertilizers, there is no real alternative to prohibiting the importation and use of those products that contain high proportions of heavy metals.
In its recent budget, the Government has taken some steps to address the issues pertaining to CKDu. Among them, two budget allocations are worth looking at. First, based on the view that CKDu is a waterborne disease, the government has allocated Rs. 900 million to supply water on tap to the affected districts. The budget speech says: ‘I propose to allocate Rs. 900 million to provide Reverse Osmosis (RO) water purification plants to villages in the North Central Province in which access to quality pipe borne water is not available in order to prevent waterborne diseases’ (Budget Speech 2013). In 2012, ‘the National Water Supply and Drainage Board (NWS&DB) has planned to expand the water supply facility to areas where kidney diseases have been spreading such as Mahawilachchiya, Medawachchiya, Padaviya and Kebithigollewa’ (Daily News, 20 December, 2012). The Government’s view that CKDu is caused by polluted water is evident in the work of the NWS&DB and the recent budget speech.
However, in their study, the WHO mission states that there is no association between drinking water and CKDu. This conclusion, arrived at by the WHO team working with a group of 45 highly qualified scientists as field assistants and several other doctors over a period of two years at a cost of Rs. 70,000,000 of taxpayer’s money, should not be taken lightly. As the Government played a key administrative, advisory and leadership role in this project, it has a particular responsibility to clarify the issue of whether drinking water contains cadmium or not. The allocation of a huge fund to supply piped water to the affected areas of the dry zone suggests not only that the Government has implicitly accepted the fact that drinking water there contains cadmium, but also that they rejected the basic finding of the WHO report. Moreover, this lays the foundation for a system through which local or central government could start levying charges and taxes on pipe borne water – a potential major burden on the disease-ridden communities of the area, and a particularly sad part of the story.
One of the major findings of the WHO mission is the role played by pesticides and fertilizers in the pathogenesis of the CKDu. The report says, ‘The mean Cd concentration of soil from the endemic area was 0.4 ug/g and is higher than the levels reported in agricultural soils in certain developed countries’ and ‘One or more pesticides residues were above reference levels in 31.6% of people with CKDu’ ‘Simultaneous exposure to nephrotoxic pesticides may be contributing to the progression of the disease in people with CKDu’. Although the WHO study reports on the adverse effects of pesticides and fertilizer use in the affected districts, it has subtly and strategically evaded making any recommendation to ban fertilizers and pesticides identified with high concentrations of cadmium and arsenic. As the former Registrar of Pesticides states, pesticide use has “increased dramatically by 237%, from 2,166 tons in 1976 to 5,144 tons in 1979, far exceeding the actual requirement of the country” (Dr. G.A.W. Wijesekara) [I don’t have recent figures]. The former Registrar of Pesticides further states that the ‘number of companies involved in pesticide imports and variety of pesticides imported has steadily increased with more companies dealing with commodity products’ (ibid), and that many of these companies seem to have ignored the International Code of Conduct. He further observes that ‘the present infrastructure and manpower for registration, distribution sales and use of pesticides is inadequate for a better regulatory scheme’. The majority of pesticide control officers in the Agriculture Department now come under the Provincial Councils where they are overwhelmed with a whole range of different tasks; pesticide control has become only one tiny part of their total workload. Pesticide control is therefore in disarray and this has resulted in improper use.
In 2011, however, the Registrar of Pesticides banned a few chemicals that were identified as causing CKDu, but after some time, the ban was lifted on the basis that the banned chemicals did not have any proven effect on the disease. In April 2013, four chemicals were banned again, following a public outcry and intensive lobbying, but so far no regulatory mechanism has been established to implement the ministerial order to ban the use and sale of pesticides. My understanding is that the Registrar of Pesticides has not been given powers to take action in cases where the pesticide regulations are violated. It is not clear what the Government is going to do with those fertilizers containing disease causing agents, which are already in circulation. Giving priority to self-sufficiency in rice over a solution to CKDu, the Government has increased the supply of fertilizer at a concessionary price to farmers. The recent budget speech says: ‘The farmers on their own suggested the need to reduce the usage of chemical fertilizer and pesticides to reduce their harmful effects on food, water quality, health, animals and the soil. Since such a shift would take some time, I propose to continue with the fertilizer subsidy scheme to provide all varieties of fertilizer at Rs. 350/per 50 kg bag for paddy cultivation during both the Yala and Maha seasons. A subsidized price of Rs. 1,250 per 50/kg bag will also be continued for all other crops’ (8.2- Budget speech 2013).
It is important that the Government should take a more responsible stand and initiate action. Policy decisions should be based on scientific findings rather than on tangible political gains, or the whims and fancies of politicians. It is important to implement the WHO recommendations, particularly with regard to fertilizers and pesticides, without delay, before the disease becomes a national catastrophe affecting the whole country.
*Amarasiri de Silva, PhD (formerly Professor, Department of Sociology, University of Peradeniya)