24 May, 2017

Sri Lanka: Stop Hoodwinking The Public Over Kidney Disease

By Amarasiri de Silva

Dr. Amarasiri de Silva

Dr. 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)

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  • 2
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    Dr. Peris@ How can we expect from a govt to take a more responsible stand and initiate action, while we are well aware of the facts who are in power would do any single issue meeting with human aspects to this date ? What I meant by human aspects is described below: a) They are not serious with law and order in general b) Normally every state would ban any kind of injurious chemicals coming in to the country in the form of fertilizers – holding very strict rules and regulations; but we the people are well aware, even container wise ethonol and hundreds of heroine are being imported illegally by the DIRECT approval of the RULING bunch these days c) Human right violation issues are becoming record high ascending from war end to this date, I feel these kidney disease could also be RULER´s tactics to harm the poor faming community indirectly
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      Correction: It should be to Dr. Silva@
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        The fertilizer and pesticide producers and companies have brought off the Ministers of Agriculture and Health. The Minister of Health, Sirisena is totally corrupt and has also failed to pass the National Dugs policy Bill, so there will be no ban on imports of fertilizers and pesticides which the regime provide at subsidized rates to the Sinhala farmers. In short the Rajapaksa regime is poising the farmers of Sri Lanka having stolen their pensions! Meanwhile they are SPINNING the misinformation – Just like Mahipala Sirisena said that a clerk had stolen the National Drugs Policy Bill! Lets hope that Sinhala farmers wake up to the truth soon and start using organic fertilizers and stop taking POISONOUS BRIBES in the form of subsidized fertilizers and pesticide for the Corrupt and criminal Mahinda Jarapassa regime.
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          There are some chinese regions that are poor than our lanken rural areas. But the chinese in general would not even see the poverty among those folks. They the chinese dont even notice when those peoples got hurt by landslides or the like natural catastrophes. So the Rajapakshes may have learnt it from them -that the pulse feeling of those poor farmers are not important to them so long their so called develpement projects keep filling their own pockets. Else, I don t see any reason why authorities to allow highly injurious chemicals to flow into the country to the manner as it is seen today. I know by myself – that DDT was already banned in rich countries – long long decades ago, but India, Srilanka and other poor countries did not ban as insecticides against eradiation of Malayria.So was the case with far poor Afro states too. There are lot more chemicals that the agro researchers have sorted out them to be away from use for various reasons: Many of them are proved to be cancerous – DDT is cancerous. DDT has been common term. There are a large variety of chemicals that are common use by farmers, should be made clear the hazardousness of these chemicals. Relevant authorities should be accoutable if they have failed to make aware those poor farmers adequately.
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            Lanka doctors should start using PROBIOTICS for treatment of Chronic Kidney Disease, which has been done successfully in the United States and recent research indicates. A Healthy gut that than neutalizes and acts as a sink for acid and chemicals relieves some of the strain from the Kidneys… Kidney Disease is not AIDS or sexually transmitted, so I do not think that the “stigma’ that is talked of in this article is that relevant or that such a huge social medical campaign with lots of sociologists is needed. People are often just too poor to want to hear the bad news..
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          You talk about pensions of farmers being stolen. They have even gone on grabing the lands of notherners and some areas in southern too. Land grabs have become one of the grave issues of those folks. My only hope is Rev. Sobitha Hamuduruwo would do all the imperative driving these marauders beyond our all sights.
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      Bomb Tamils in Sri LANKA TO OBLIVION, Appoint a Tamil to be the VICE President Of Sri Lanka AND THEN TALK ABOUT HUMAN RIGHTS. That should have been the way.
  • 4
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    Both the govt, bureaucrats and doctors are worried about what can get from the system, and they all say hell with the rest. That is all.
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    A most informative article. As I read the many articles on this subject, I cannot but help recalling an observation sometime ago, when on a project, I witnessed the haphazard application of fertiliser and pesticides, oblivious to the recommended levels, by those undertaking the work. Clearly, education has a part to play.
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    Special Projects Minister S. M. Chandrasena will submit a Cabinet paper on a priority basis to declare chronic kidney disease high risk areas. Dr. Channa Jayasumana, Senior Lecturer in Medicine of the Rajarata university, spelt out the objectives of the project at a media conference held at Special Projects Ministry on Wednesday (6). http://www.island.lk/index.php?page_cat=article-details&page=article-details&code_title=97368 Around 50 percent of agrochemical products in Sri Lanka contain the dangerous chemical Glyphosate, although companies often hide the chemical behind various trade names, according to researchers. Studies conducted by Dr. Channa Jayasumana of the Rajarata University show that the chemical Glyphosate found in agrochemicals has an adverse effect on humans when it enters the system. His findings suggest that due to its composition, Glyphosate is quick to mix with ‘hard’ or Kivul water. This, in turn, acts as a carrier of arsenic and heavy metals to the kidney. Due to the hard water and metals, the harmful chemicals remain in the kidneys for a long period, thus causing kidney disease. – See more at: http://www.nation.lk/edition/news-online/item/25745-fifty-percent-of-agrochemicals-harmful.html#sthash.GgUI2oEY.dpuf It seems that the culprit has finally been indentified. However this particular chemical has been flagged and under scrutiny since as far back as June 2004. Ten years and thousands of lives later we have made this discovery. ‘Be cautious in using glyphosate for weed control in tea’ by Dr. Kapila Prematilake (Senior Research Officer), Low Country Station, Tea Research Institute, Ratnapura and B.P. Ekanayake (Officer-in-Charge), Mid Country Station, Tea Research Institute, Hantana, Kandy. Glyphosate herbicide, when sprayed to the weed foliage gets translocated to all plant tissues and effectively kills the entire plant including rhizomes of perennial weeds. Ability of killing wide range of weeds makes Glyphosate one of the most versatile herbicides. Thus, most of the tea estates and smallholders heavily depend on glyphosate for weed control. Glyphosate (36% a.i.) is marketed in Sri Lanka under different trade names. Wilting tea plants However, indiscriminate use of glyphosate on tea lands has adversely affected health and productivity of the tea bush in the recent years. Furthermore, increasing levels of glyphosate residues have been reported in our tea exported to other countries http://archives.dailynews.lk/2004/06/24/fea05.html
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      According to Dr. Jayasumana, it is the Arsenic in the agriculture that is the culprit. It is not enough to even have arsenic. The water must also be hard. Apparently, all this is supported by Natha Deiyyo who had spoken to a lady that Prof. Nalin de Silva had consulted. The WHo found no arsenic, it also did not find much cadmium, but I guess the WHO has to blame something.
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    My first wife died from complications of end stage renal failure. The disease destroyed her slowly and we had to sit there and watch her die. The sad thing is that with a little bit of knowledge it is avoidable and with the right treatment it is treatable. Any government that has any claim to call itself caring and a government for the people have no right to do so if they fail to act on this disease.
  • 0
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    Edifying article, Dr Amare! But our gullible hoi polloi, surely, will continue to drink what Sanga & Mahela drink & go buy instant & fast food,in the ‘super’, where the former is the “nutritionally qualified idol”%%%
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    “It is important that the Government should take a more responsible stand and initiate action.” The UPFA government is incompetent and can never take any responsible actions. Even the children milk powder saga they messed it for several months. They killed people who asked clean drinking water. PM still at large who was caught red handed involved few hundred kilos of heroine import. There are several good reccommendations from WHO, local university dons etc to clean up the Cd in the system to rectify the CKDu. But what can expect from an incompetence government?
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    Dear Dr Silva This country does not need scientists.There are enough politically oriented medical persons and psuedo scientists (with historical records of political interests) to guide the government. There is no point of wasting our time to show the truth to the persons in power or the persons guiding those in power. We are a lost nation living by selling heroin. a country selling heroin will not worry of human deaths, by whatever mechanism
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      I can understand your pain. This I pulsed by watching LANKEN news yesterday. Many those who shamelessly advocate ” ira handa wage wisawasai 5/6 , of the votes would be gained by them in Southern PC election”, THEY ARE CERTAIN ABOUT THE OVERWELMING VICTORY OF THEIR PARTY – have no any arguments when posing about the large scale-drug businesses or ethorno containers keep reaching the island with the direct approval of the top men in power today. I now believe what matters to the masses – that starve in the country, that are the majority rural folks and the voter base for Rajapkshe would just be satisfied if they are given few meals to surive these days. They would never go into the details how RAJAPAKSE admin sacked the CJ -Dr. SB being totally against to the prevailing constitutional provisions, they would not see why journalists are being assualted, tortured, murdered not respecting the dissent; they would no care of anything that the knowledgble fractions in the country focus on… SO this Rajapskses have targeted to stay in power by making them hopeful at least in election days – like HINDI films would bring the poorest of the poor in India to their dreamy fantasies at least for few hours. So has MR acted sofar – he had travel to Tangalle yesterday, reported as by a Bus – just to check it by himself – boasting quick travels within the country, that his development projects made it a reality, etc to target poor vulnerable, gulible, naive village folks. Premadasa also did the same job in different ways to attract those poor folks and live on their votes.
  • 0
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    The regime’s actions are dependent on the amount of commissions they can get from a deal. Importers of pesticides may have found a way to grease the palms of those concerned to flood the market with toxic pesticides. Do these people care about human lives when their lives revolve around money and money alone? These are issues which should be highlighted by the opposition. It is the opposition’s duty to educate the masses, not only for their vote, but also to safeguard the rights of the people. Can we expect them to rise up from their slumber, at least now?
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      Have we had CKDu – like diseases in lanka or any other developing world? No, not even the days immediately after Mahaweli project was introduced to the those people. Publications prove that all these new forms have been found in young poplations within the last 10 years only. This alone could have been the reason for authorities to pay wholehearted attention long back saving the lives of the poor farmers. Today is already too late.
  • 0
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    So much has been written by professionals in the medical, scientific, academic and agricultural fields on the subject of CKDu that one wonders why the government has not embarked on a large scale programme to combat this disease. Perhaps there is confusion in pin pointing the cause. Is it Cadmium, Arsenic, Fluorides, or is it a combination of some or all of these? In this authoritarian, dictatorial, government where power rests with one person, are those in positions to make decisions, reluctant to stretch their necks out and await orders from the Sun God? Whatever it is, some interim measures are necessary to regulate imports and use of fertilizer and agro chemicals based on minimum levels of toxic metals, along with publicity and education. My advice is to get on with it.
    • 0
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      what do you expect from a govt that openly neglect the 2.5 cement packages sized heroine found illegally imported to the country – to control over the far injurious agro chemicals. It is like asking Jaliya Wickramsooriya to promote srilanka – knowing that JW has nothing but tea taster experience to approach the diplomatic arenas. What angers me, even if significant numbers of human losses are the case through CKDu, the authorities to stay dumb and deaf.
  • 0
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    Cut out kidneys from Tamils and implant into Sinhalese who need them. Problem solved.
    • 2
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      Fatima Fukyu-shima, you are a total jerk. You must have had a terrible, deprived childhood. You need help. Seriously. Get it soon and then start writing sensibly. Please.
    • 1
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      Fathima Fukushima Why the editors allow this guy to comment on this important and serious topic like this??. His comments are totally biased and nonsense.
  • 0
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    Sad thing is most farmers continue to be ignorant of the extremely hazardous nature of these pesticides and other Agrochemicals. Educating the farmers is key to the prevention process, I still hear farmers calling some of these pesticides “beheth” [medicine]. First thing to do is to get farmers to call all these pesticides as “Wakugadu Maraya” [ultimate kidney killer]so they will start treating such product with extreme caution and try avoiding it as much as possible.
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    I found the recommendations made by the WHO following their study. 27.9.13 Final Mission Report : Research on kidney disease of uncertain aetiology (CKDu) in Sri Lanka; National CKDu Project Dr Shanthi Mendis M BBS, M D, FRCP, FACC Director Management of Noncommunicable Diseases World Health Organization Geneva, Switzerland The summary results of the National CKDu project, which was conducted at the request of the Ministry of health with technical support from the World Health Organization (WHO) have been reported in a peer reviewed international publication in BMC Nephrologi on the 27’h August 2013. Details are provided in the final report submitted to the National Science Foundation, which funded the study jointly with WHO. In the 15-70 year age group, the age standardized prevalence of CKDu is 16.9% in females and 12.9% in males. Severe stages of CKDu are more frequently seen in males. The prevalence of CKDu increases with age. Results also indicate that multiple agents are playing a role in the pathogenesis of CKDu. There is evidence of chronic exposure of people in the endemic area to, low levels of cadmium, through food and also to potentially nephrotoxic pesticides and other agents. Significantly higher excretion of cadmium in urine in CKDu cases compared to control subjects and the dose effect relationship between urine cadmium and CKDu stages indicate that cadmium is a risk factor for the pathogenesis of CKDu in Sri Lanka. There may also be exposure to arsenic and lead. There was no dose effect relationship for arsenic, lead and CKDu. The concentration of arsenic, cadmium and lead in water are within international reference limits. Cadmium levels in soil and certain food items and tobacco in the endemic area are higher compared to nonendemic areas. High levels of cadmium, arsenic and lead I were found in ” some samples of phosphate fertilizer and pesticides/weedicides. Deficiency of selenium and genetic susceptibility may be predisposing factors for the development of CKDu, when people are exposed to nephrotoxins. It is most likely, that oxidative stress and tubular damage which develop with low cadmium exposure is aggravated by nephrotoxic pesticides, other heavy metals such as arsenic and lead, deficiency of protective factors such as selenium and genetic susceptibility. Findings from yet unpublished studies, show that angiotensin converting enzyme inhibitor, enalapril, has a significant effect in reducing albuminuria due to CKDu. Further, there is evidence that herbal remedies prepared with aristolochia indica { Sasanda or Sapsanda ), containing nephrotoxic aristolochic acid are ingested as remedies for certain ailments. Further studies are ongoing to investigate the contributory role if any, played in the pathogenesis of CKDu by infections. Longterm prospective studies are required to make conclusive aetiologic interpretations. A body of scientific literature demonstrate that the dynamics of intake of cadmium by plants {food) are influenced by many environmental factors including, pH and buffering capacity of soil, composition of soil, water quality, temperature and rainfall. These factors are different in different parts of the country. Further, many factors impact on the way oxidative damage caused by cadmium progresses to end stage renal disease. They include exposure to other nephrotoxins, inadequate intake of water, dehydration and heat stress, high fluoride, calcium and magnesium content of water and other illnesses such as diabetes and hypertension. CKDu is a public health problem which appears to have developed insidiously over more then two decades. It is not scientifically feasible to provide conclusive answers to all aspects of this public health problem through this study conducted over a period of 27 months. Further, as there were very limited published data on CKDu when this projected was mooted, the design of the research proposal had to cover multiple aspects of the problem. This prevented in-depth studies in anyone area, such as analysis of food and soil. However, the findings of the study are adequate to take immediate policy measures which can be suitably modified as results of further investigations emerge. Based on the above, as well as the life threatening nature of kidney disease, the following ten recommendations are made to protect the general population particularly the younger age groups, ensure timely diagnosis and treatment and to prevent the spread of the condition to other areas of the country. 1. Supply drinking water to_ households in the endemic area to mitigate the potential harmful effects of high fluoride and high calcium in water, heat stress and dehydration which may aggravate the effect of kidney damage caused by nephrotoxins such as cadmium. 2. Strengthen the regulatory framework to improve quality control of imported fertilizer particularly cadmium, arsenic and lead levels in phosphate fertilizer and curtail the indiscriminate use of synthetic fertilizer. 3. Regulate the quality of imported pesticides/weedicides to prevent contamination of the environment with heavy metals. Ban the use of diazinon, propanil, paraquat, chlorpyriphos and carbaryl which have been shown to be nephrotoxic in animal experi ments. 4. Implement comprehensive public health measures to safeguard the health ofthe general population including farmers through i) education on the appropriate use of fertilizers, weedicides and pesticides ii) compulsory provision of safety clothing , gloves and masks at the point of sale of agrochemicals, iii) control of the sale of agrochemicals which are known to be nephrotoxic e.g., diazinon, propanil, paraquat, chlorpyriphos and carbaryl, iv) creating awareness of the importance of adequate fluid intake and.nonsmoking. v) education on cooking practices i.e. avoid the use of water from irrigation canals for cooking and drinking vi) advice to avoid the use of lotus yams from the endemic area as their content of cadmium is above stipulated levels vii) Advise on appropriate disposal of nickel Cd batteries, bottle lids etc 5. Strengthen tobacco control measures to protect people, from the harmful effects of tobacco use including potential health damaging effects due to high cadmium content in tobacco grown in this area. 6. Regulate the use of herbal medicines containing aristolochic acid as it is an established nephrotoxin which has been shown to cause kidney disease in other parts of the world. Create awareness among the• public and medical personnel regarding the ill effects of indiscriminate use of certain western medicines such as nonsteroid analgesics on the kidney. 7. Strengthen ongoing efforts to improve access to health services with special attention to early diagnosis and treatment at the level of primary health care institutions including through scheduled clinic visits, access to laboratory tests and treatment with enalapril. 8. Provide social welfare support to affected families and an allowance to patients diagnosed with CKDu to prevent them from becoming more impoverished and undernourished. Inability to purchase food can cause iron, folate, antioxidant and trace metal deficiency which will increase the susceptibility of people to harmful effects of nephrotoxins. 9. Facilitate research giving priority to research in actionable areas which can provide affordable and pragmatic solutions for addressing this public health issue e.g. i) implementation research related to the above policy measures ii) methods to reduce the intake of cadmium by plants iii) use of local rock phosphate and environmental friendly organic fertilizer iv) development of rice strains which require less fertilizer and are resistant to pests v) nephrotoxicity of pesticides and weedicides vi) total diet studies on heavy metals and other nephrotoxins vii) role of protective factors such as selenium viii) ways to reduce pollution of the environment including air pollution ix) longterm prospective and interventional studies to make conclusive aetiologic interpretations x) barriers that prevent translation of scientific evidence to multisectoral action and policy. 10. Set up an accountability framework, for monitoring the implementation of the above multisectoral measures using time bound targets. The high level Cabinet Sub Committee and the Parliamentary Select Committee are well placed to oversee this function.

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