To prevent the chronic kidney disease of multi-factorial origin (CKD-mfo) affecting the North Central Province (NCP; Rajarata), it is essential to: (a) embark on a country-wide awareness programme on environmental protection, (b) strictly implement environmental laws, country-wide, (c) educate farmers on the prevention of water and environmental pollution and taking proper safety precautions during the handling of agrochemicals and petrochemicals, (d) ban spraying and applying chemicals just prior to harvesting and transportation of fruits and vegetables, (e) control all chemical fertilisers and toxic agrochemicals, (f) provide clean and safe potable water to entire Rajarata residents and other affected areas, (g) pass a “Clean Air and Water Act” in 2014, and (h) embark on a broad-based, root-cause-oriented, real-time, geo-water–environmental and socio-medical, prospective research programme covering the entire region that lasting over 10-years. The goal should be to prevent CKD-mfo and other escalating chronic non-communicable diseases (NCDs). Implementing a programme with a well-coordinated synergistic plan should prevent farmers from falling victim to renal failure, premature death, and massive social, economic, and family disruptions. Such a preventative action plan should include all stakeholders to maximize resource utilization, in coordination with the philanthropic and private sectors.
Clean water taken for granted:
Despite being a basic need, clean water is not readily accessible for more than two billion people in the world. Clean water and sanitation can make or break human development and societal survival. Water is fundamental for all of us. Access to clean water is an important social indicator of human progress that is necessary for healthy growth in the country. Life expectancy in any country is directly relates to the provision of clean water and safe sanitation, rather than on economic or structural developments, or the provision of medical or materialistic comforts and advancements. The failure to invest financial, moral, and political capital in providing clean water to NCP will lead to loss of fundamental opportunities, lack of social and economic progress, ethnic disharmony, and increase sickness and premature deaths of farmers, loss of productivity, and consequent economic downturn.
People are familiar with sewage- and bacteria-related water pollution leading to dysenteries. Overcoming the microbial contaminations is relatively easily, but it is difficult to dispose of chemical pollutants. Microbial contamination occurs via sewerage and septic systems, wildlife, and livestock operations, but the chemical contamination of water is either natural or via anthropogenic causes, such as agrochemicals, storm water runoff, industrial and domestic wastewater, and through farming.
Solving such a massive problem is not simple. In addition to the funds needed to implement the remedial process, it also need a humanistic approach, political will, moral, and the courage to move ahead and setting of proper priorities. For sustainable and cost-effective ways to overcome water and sanitation crisis also need private–public partnerships with all stakeholders and commitments from the government.
Kidneys and human health:
Kidneys are essential for the removal of waste and toxic products from the body. The kidneys also balance electrolytes and chemicals constituents in body fluids, excrete foreign and toxic metabolites and other unwanted substances, regulate blood volume and blood pressure, produce active vitamin D, and facilitate production of red blood cells in bone-marrow through the hormone, erythropoietin. Kidneys are vital, but once conditions are unfavourable and exceed the thresholds, kidneys will fail.
Kidney fibrosis, known as tubulo-interstitial sclerosis, occurs early in CKD-mfo and is irreversible, so prevention is the only cure. Contrary to the popular belief, there is no medical solution to the CKD-mfo. Moreover, there is no evidence suggesting CKD-mfo is an immune, congenital, genetic, or infectious disease. CKD-mfo is a chronic disease acquired through environmental exposure. Thus, real-time, long-term bio-surveillance is essential to understand and curb CKD-mfo.
Chronic Kidney Disease (CKD-mfo) in Rajarata:
Over the past 15 years, the orator has studied water contamination and human health, including CKD-mfo in Rajarata. There are controversies and confusions about the published investigational methodologies, disparities of findings, and conclusions made with reference to CKD-mfo.
CKD of unknown origin/aetiology (CKDuo/CKDu)—CKD-mfo is not unique to Sri Lanka. Similar, high incidences of CKD-mfo was reported in other dry-zonal agricultural societies, including Balkan nephropathy, La Isla Chichigalpa, Kashin-Beck nephropathy in China, and South American CKD of unknown origin, CKDuo.
The CKD in the dry zone in Sri Lanka is an “environmental–exposure” disease caused by “multiple factors” coming together―thus the correct terminology; CKD-mfo, which is spreading across the NCP and to other districts in Sri Lanka. Figure 1 illustrates the proposed potential causes for CKD-mfo. However, none of these factors could singly, at their reported contamination levels, neither cause renal failure nor explain its geographical distribution.
Little attention paid to several other plausible causes of nephrotoxicity (toxins that harm kidneys). These include the overuse of nephrotoxic nonsteroidal anti-inflammatory agents (i.e., most painkillers, except paracetamol), use of illicit drugs and alcohol, leptospirosis, smoking locally grown tobacco, petrochemical contamination, unsafe working conditions, long-term consumption of polluted water, and as-yet unidentified toxins. CKD-mfo is due a combination of some of these.
The prevalence of CKD-mfo in Sri Lanka geographically demarcated within the dry zones. However, it is gradually spreading to adjoining areas in NCP and to distant areas, such as Badulla and Hambantota districts as well. Distribution of patients with CKD-mfo is not uniform and does not co-inside with hard water/salinity/ionicity distributions. Most affected are agricultural areas, where 90% population lives in rural communities with little access to modern amenities, potable water, sanitation, and medical facilities. This disease primarily affects (and kills) 30- to 60-year-old, male farmers.
People living in villages should have access to clean, potable water such as that enjoyed by city dwellers. However, this may take further three or more decades to materialize. In the absence of efficient interventions, during the next 30-years, over 250,000 Sinhala people, predominantly middle-aged farmers will die of CKD-mfo. If the rate of premature deaths from CKD-mfo continues in the NCP, there will be less than 10% of adult males surviving in the region by the year 2040. This not only would devastate families but also markedly change the demographics of the NCP and adversely affect the country’s rice sufficiency, employment, and the economy.
Practical way forward to curb CKD-mfo:
Approximately 55% of Sri Lankans rely on shallow and deep wells and streams for drinking water. It is the duty of the Water Supply and Drainage Board (WS&DB) to provide clean water through constructing networks of pipes, central purification facilities, and overhead tanks. In the interim, philanthropic organisations are the best resource for providing clean water cost-effectively to NCP.
There is no doubt that the provision of centrally purified, pipe-borne water is the best, safest, and most cost-effective solution in the long- term. Thus, over the past decade, the writer has recommended to successive governments to earmark additional 10% funding for the WS&DB for water-related infrastructure expansion for the NCP. Currently with approximate 2% funding and efforts, it may take more than 50-years before the WS&DB would provide pipe-borne water supplies to this region. Even with 10% funding per year, it would take 25-years for people in NCP to have pipe-borne clean water. Are we going to wait that long to provide clean water to Rajarata people?
Consequence of not providing clean water to Rajarata:
The death rate from the CKD-mfo, approximately 13-deaths per day, is far outweighing the “death rate” attributed to LTTE terrorism, and the overall deaths from the 2004 tsunami.
Delays in implementing concrete solutions in the NCP enhance premature deaths and harm the rice production in NCP. This happened after Chola invasion hundreds of years ago, when invaders destroyed hundreds of cascade reservoirs. This led to an epidemic of mosquito-borne diseases, particularly malaria that forced Rajarata residents to vacate the territory. Unless we take firm actions now, CKD-mfo could lead to a similar abandonment of Rajarata. It will leads to a loss of 40% of the country’s food-production and third of the Gross National/Domestic Products that originates from the NCP. Would the government and the rest of the country continue to be blind to this matter?
Long-term strategies and environmentally friendly agricultural methods:
In addition to the mentioned preventative strategies, agricultural research programmes should focus on generating naturally pest-resistant, high-yielding seed varieties and ones that thrive on compost and other natural fertilising methods. The government must, (A) reconstruct all abandoned cascades of tanks and ancient irrigation systems and construct villages around these tanks; (B) embark on strict quality control and distribution of all chemical fertiliser and toxic agrochemicals; (C) take measures to restore soil, air, and healthy natural environment; (D) encourage farmers to use natural cultivation methods including local, high-yield seed varieties, and minimize the use of toxic agrochemicals to pests and weed control; (E) prevent the growth of mosquitoes and other harmful pests; and (G) encourage soil and water conservation based on a new, “Clean Air and Water Act”.
All these must be a part of the long-term strategy to improve the health, wealth, well-being, and prosperity of the nation (food + agriculture + clean water + healthy environment = Health).
Missing items to solve the puzzle:
Preventive medicine needs focussing on synergising efforts and maximising the use of resources. Meanwhile, the potential role for cross-subsidies and transfer from higher-income to lower-income users in utility pricing is worth exploring. Water and a clean environment are national treasures; so everyone has the responsibility to protect these. Thus, water management needs non-political and multi-organizational input. High-priced water is not in the interest of public or public health; thus, water should never privatise in Sri Lanka.
The water–sanitation disconnect delays the progress of a society. It is not possible to sustain one without the other. In addition, we need to incorporate a broad-based, environmental and socioeconomic research programme across the NCP, covering all CKD-mfo affected areas.
Inadequate food security and food safety together with the ingestion of contaminated water and food leads to many chronic health issues, including CKD-mfo. Due to the inadequate environmental law enforcement, exposure to toxic agents in cities and occupational environments has becoming a common occurrence in Sri Lanka. Country needs a well planned and executed preventative measures to curb the epidemic of CKD-mfo. Charitable organization such as The Consortium of Concerned Philanthropic Organisations (CCPO) is the most suitable to undertake this task.
The CCPO will:
Launch an extensive awareness campaign on the prevention of environmental pollution.
B) Educate and encourage farmers to use less chemical fertiliser and less toxic agrochemicals.
C) Encourage and facilitate the government to reduce phosphate in fertiliser and the agrochemical subsidies. The latter has led to massive overuse of chemical fertilisers and pesticides, resulting in soil and water pollution and harming the environment.
D) Educate and provide protective gear to farmers: http://www.ijetae.com/files/Volume3Issue12/IJETAE_1213_14.pdf
E) Professionally install reverse osmosis plants and other water purification methods in the region to provide clean water to all affected villages within the next 24 months.
F) Carry out a truly multi-disciplinary, real-time data collecting, long-term (i.e., over 10-years) geo-water, health and socioeconomic, prospective research programme covering the entire region.
In light of the status, none of the government ministries or departments, including the WS&DB, alone is unable to accomplish this diverse task, but the CCPO can accomplish these goals timely, cost-effective manner, preventing thousands of premature deaths caused by CKD-mfo.
The core attributes of water security, sufficiency, safety, acceptability, accessibility, and affordability need recognised when providing a domestic water supply, regardless of whether they are urban or remotely located communities. The provision clean water is one of the greatest challenges facing economically disadvantaged countries in this millennium. Pure water is in abundance, but making it available at a price that is within the reach of all is what important.
There are serious concerns about the health impacts of climate change, water and air pollution, global warming, and the ecosystem degradation. Funds customary allocated to former projects as those Mahaveli should be use to restore thousands of abandoned cascades of ancient tanks and for village-level developmental activities to revitalize and empower rural communities. Overuse of the finite reserves of non-renewable energy, accumulation of waste, and misuse of water resources further compromise potable water. We must explore new paradigms in light of changing situations and take prompt actions. The country needs to preserve the environment and protect the natural reserves and nature, not only for the present but also for future generations.
The CCPO will embark in this challenge, including providing clean water to all affected villages, within 24 months. In addition, the project will embrace the provision of sanitation―toilet facilities. We look forward to the government and those who are concerned with the plight of people of Rajarata to undertake meaningful commitments and provide necessary funds to the CCPO to implement sustainable preventative actions. The aetiology of CKD-mfo is unknown but not complicated, and the solutions are straightforward. We need a cost-effective, sustainable, global solution to alleviate the CKD-mfo in Sri Lanka.
The great volunteer Colonel Henry Steel Olcott endowed with ability of integration of skills, innovations, and inventions coupled with ethical, competent leadership with product/services management skills. Col. Olcott was a broad-minded, practical man, an expert in agriculture. If he were alive today, he would recommend a plan similar to that indicated above to overcome the environmentally induced CKD-mfo in Rajarata. An expanded version of this 2013–Col. Olcott oration to eradicate CKD-mfo is available as a book¾“White Paper.”
Let us all join hands, the learned and the not so learned, the mighty and the meek, the rich and the poor, the Buddhist and the Christian, the Muslim and the Hindu, to safeguard Hela, our only Homeland, the land we love and cherish, the land you value most, in order that we all live and let live, so that we are able to leave a better world for generations of our descendants!
“Let us do the Right Thing [Prevention of environmental pollution and the provision of safe, clean water to everyone in the NCP] for the Right Reason [to save lives]”