Chronic kidney disease in Rajarata, worse than tsunami

by Prof. Sunil J. Wimalawansa

Safe drinking water is a fundamental human right, but more than 2.0 billion people in the world still lack access to safe-clean drinking water and to sanitation; Sri Lanka is no exception. Contaminated water and poor sanitation claim more lives than any war or any single disease. Toxic chemicals or organisms affecting health cannot necessarily be seen, tested, or smelled. Provision of clean water and sanitary facilities can save over 3 million lives globally and about 10,000 in Sri Lanka, annually.

Geographical and other issues

Chronic Kidney disease (CKD) primarily affects middle-aged farmers. The CKD of multi factorial origin (CKD-mfo) in Sri Lanka is geographically demarcated, but is spreading to adjoining areas around the North Central Province (NCP) and elsewhere in the country. The farming communities are predominantly affected; of which more than 90% live in rural areas with little access to medical or preventative health facilities. Currently, the CKD-mfo-prone areas cover approximately 20,000 km2, and potentially affecting about 2.8 million Sri Lankans.

The occurrence of CKD is likely dye to consumption of polluted water/food, or yet unknown and thus, uninvestigated cause. Adverse environmental conditions, recent environmental unfriendly irrigation and agricultural methods, excessive use of phosphate-rich (and perhaps contaminated) artificial chemical fertilizer and toxic agro-chemical, and mishandling of petrochemicals, all may play a role in causing CKD-mfo; but no causality is demonstrated. It is paramount to launch an island-wide campaign to reduce the usage of artificial chemical fertilizers and toxic agro-chemicals, which necessitates gradual reduction of agro subsidies. All available data suggests that the CKD-mfo is an "environmentally" acquired disease.

Causes and incidence of CKDu

The water and food in the certain affected areas is polluted with low levels of toxic heavy metals, cadmium, arsenic, and lead, as well as with flouride, and toxic agro-chemicals and petrochemicals. Although the specific cause for the CKDu is unknow, it is of multi-factorial origin, and is due to a combination of chemicals and toxins that are prevent in this area. However, CKD-mfo can precipitate in the presence of other pollutants and toxic components that have not yet been investigated. The exact incidence or the causes of CKD are unknown, but over 100,000 people are currently affected (up to 10 to 15% of people in certain villages); unfortunately, the incidence continues to increase. Therefore, an urgent, cost-effective solution is necessary.

The reality

Approximately 400% of the inhabitants in Sri Lanka have access to clean, pipe-borne water supply. It is the prime duty of the Water Supply and Drainage Board to provide clean water via the same system to the remaining 60% of the population. People live in

villages should have the same privileges of having clean potable water provided via centrally purified pipe-borne water supply, that enjoy by the city dwellers. However, this may take another three decades or more to materialize fully. Unless intervene now efficiently, by then an estimated 250,000 predominantly middle-aged farmers will be succumbing to CKD-mfo.

There are no curative measures for those who acquire CKD-mfo, thus, prevention is the only way forward. Other than providing centrally purified pipe-borne water or clean water via reverse osmosis method, there is no other sustainable way of providing clean water to the affected villages, most of which are located in remote areas.

However, this must be implemented systematically and based on scientific basis. None of the variety of commercial filters that has been introduced to the area seems capable of removing the potential chemicals and toxins efficiently.

Methodologies

The North Central region desperately needs a cost-effective way to provide safe and clean water for its farming populace. Our analysis indicates that the Reverse Osmosis method is the most cost-effective, sustainable and environmentally friendly system than can remove all toxic components from the brackish water in NCP. However, not all reverse osmosis units are the same. Thus, it is imperative to install the right reverse osmosis water purification unit in a given village to provide clean water. Depending on the water quality/turbidity, electrical conductivity, chemical constituents, turbidity, etc., a pre-filter is necessary for the RO units. Philanthropic organizations and the water board are currently installing pilot units in villages in the Anuradhapura district. However, the Rajarata area requires approximately 400 of these reverse osmosis unites to provide clean water to its inhabitants.

Education, awareness and pollution prevention campaign

It is utmost important to initiate a region-wide awareness campaign on prevention of environmental pollution. This educational program must include (A) consequences of drinking contaminated water, (B) the importance of using safe and clean treated water, (C) water conservations methods, prevention of pollution of water sources and the environment, (D)essential precautions to be taken by farmers when using agrochemicals, (E) utilization of locally available organic substances and compost for cultivation and for pest control, etc. We have an on-going village level educational cum informative campaign on this since 2008; however, this needs to be intensified.

Provision of clean water to Rajarata

1. Prioritisation of villages to provide reverse osmosis water purification units.

2. Identification of the right RO units for the right village: as cost-effective, practical and sustainable way to provide clean water - via water treatment technology (removing all potential pollutants).

3. Availability of sustainable sources of brackish-water and method for clean water distribution.

4. Set-up infrastructure for proper operation and long-term maintenance of reverse osmosis plants.

5. Awareness program to encourage people to use clean water for drinking and cooking.

6. Regular monitoring of water quality as an integral part of the operation and maintenance.

7. Long-term data collation and systematic assessments to eliminate health problems in the region.

8. Capital, operational, maintenance and distribution costs; and cost recovery method.

Cost of installation reverse osmosis plants

On average, reverse osmosis plants costs about Us $8,900 to install (cost varies from $4,000 to $25,000, each unit). An average reverse osmosis unit provides safe and clean water to approximately 1,500 people (one or a cluster of 2 to 4 villages). We estimate that the entire region requires approximately 400 reverse osmosis plants, at a cost of US $4 million (500 million Sri Lankan rupees).

Cost-effectiveness

The number of deaths secondary to CKD in the affected region currently approximates 5,000 year. In spite of the diagnostic underestimations, this amounts to deaths of 13 farmers a day. Thus, each $650 spent on this project will prevent one CKD death per year. Therefore, over the expected life span of 30 years of an RO pant, investment of US $24 will prevent one death in Rajarata. Therefore, the proposed region-wide intervention is highly cost-effective.

With an estimated rate of 1% CKD-mfo related deaths, each reverse osmosis plant prevents approximately 10 deaths in a village, per year. Thus, over a 30-year period, each reverse osmosis plant will save about 300 lives. There is no medical or any other intervention where one could offer a solution to this region that is more cost-effective in reducing diseases burden and premature deaths.

Expectation and the hypothesis

The provision and the consumption of clean water will prevent the new occurrence of CKD-mfo. It would also decrease other chronic diseases and diarrhoeal diseases prevalent in the region. In 2012, department of health spent 3.6% of its annual budget, 350 million rupees to treat patients with CKD-mfo, and this cost is escalating. We estimate that the implementation of this proposed broader project would save about 500 million rupees per year in the health department budget alone. In addition, improvements in health reflect with increase productivity. Especially paddy and other agricultural productions in the region. Therefore, a rapid capital cost recovery is expected after commencing this project.

Current priorities:

Commitments and raising funds

A) Regional island-wide educational campaign on prevention of water and environment pollution.

B) Provision of clean, safe portable water using RO systems to CKD-affected villages in Sri Lanka.

C) Broad-based, environmental and sociological research program for CKD-mfo affected areas.

D) Government to provide adequate funds, and to develop collaborations and private-public partnerships, particularly with the not for profit sectors to implement the project and its longer-term maintenance in the region.

Once funds allocated, the Consortium of Concerned Philanthropic Organisation will (A) launch a extensive awareness campaign on prevention of environmental pollution and encouraging farmers to use less agro-chemicals, (B) professionally install reverse osmosis plants in the entire region providing clean water to all affected villages within the next 18 months, and (C) carry out a truly multi-disciplinary, prospective, long-term geo-water, health and socio-economic research program that covers the entire region. In addition to providing clean water, proposed project will also embrace on the provision of sanitary and toilet facilities. We look forward to undertaking a firm commitment by the government, provides adequate funds for the Consortium to implement this sustainable and extensive plan.