Chronic Kidney Disease of Unknown Cause

Tuesday, 22 April 2014 00:20 -     - {{hitsCtrl.values.hits}}

  • Policy paralysis
It is reported that Chronic Kidney Disease of Unknown Cause (CKDu) is decimating the young male population of the North Central Province, parts of Uva Province and even reportedly in the Central Province, North Western Province and Eastern Province. A case study has found, together with anecdotal evidence, that the most vulnerable group are men over 40 years of age, who have been working as rice farmers for over a decade. A hypothesis has emerged that consistent exposure to agro chemicals, combined with hard work in the hot sun, dehydration, hard water, and allegedly, in addition, heavy consumption of illicit liquor, among factors combined with others is the cause for this epidemic. Chronic renal failure is a degenerative, progressive condition marked by the gradual loss of kidney function. The kidney serves the human body as a filter and once they are damaged the body can no longer remove waste and excess liquid and thereby purify the blood. In normal circumstances CKD is caused by obesity, high blood pressure and diabetes. The disease has been classified as having five stages, one being the mildest and five the severest. Stages one and two lead to reversible kidney damage, while stage three and beyond cause permanent damage. In countries such as ours, where the opportunity for dialysis treatment is limited, stages three and four will develop into stage five. Without the kidney transplant, stage five is terminal. CKD generally affects older patients. On the other hand CKDu is associated with heavy labour in hot climates particularly among agricultural worker, such as those working in rice cultivation. CKDu affects young men. In the first stages deteriorating kidney function causes symptoms such as general fatigue and loss of appetite. For this reason young patients do not realise that that they have CKDu until they are already very sick and have sustained irreversible kidney damage. Because the renal function declines at a gradual rate, death from CKDu is often slow and extremely painful. The experience is extremely traumatic not only for the workers but also for their families who are frequently unable to afford the cost of transportation to a medical facility with dialysis services and the cost of treatment itself. CKDu is optimally treated with either dialysis or a kidney transplant. Both are expensive and difficult processes unavailable to thousands of poor patients affected. Padaviya: A patient in every farming family In Sri Lanka’s rice bowl, areas such as Padaviya, patients diagnosed with CKDu, whose very survival depends on dialysis, when referred to the Anuradhapura Base Hospital, where dialysis services are available, mostly are simply taken home to die, as they cannot afford the cost of travelling from Padaviya to Anuradhapura on a regular basis for dialysis treatment. This was before the dialysis treatment unit was set up at Padaviya Base Hospital with donor support, an initiative by a committed medical practitioner serving at Padaviya. A round trip to Anuradhapura to Padaviya and back would cost around Rs. 5,000, including accommodation and food for an accompanying family member. This was clearly unaffordable to the subsistence rice farmers of Padaviya. The stories of the patient’s medical histories are disturbing. A 45-year-old father of three from Weli Oya realised he was ill eight years ago when he lost his appetite and was inflicted by severe headaches and prone to attacks of dizziness. His condition has worsened in the last few years, notwithstanding treatment by dialysis on a regular basis at the Padaviya Hospital. Many families cannot afford the regular trips for dialysis and the related costs to be incurred and simply take back the chronic patient back home to die. It has been recorded that Padaviya with a population of around 31,000 people has 2,695 CKDu patients. An adjacent area, Medawachchiya, with a population of 56,000, has only 3,125 patients. This disparity in numbers is explained by the remoteness of Padaviya and the large percentage of people involved in rice cultivation. Residents of Padaviya claim that there is virtually a CKDu patient in every farming family, and funerals of people felled by CKDu are a virtual daily occurrence. The geographical area the Padaviya Hospital serves includes the Kebithigollewa and Wahalkada areas in the North Central Province, Sampath Nuwara and Weli Oya in the Northern Province and Siripura and Pulmoddai in the Eastern Province. In June 2013 the dialysis unit in Padaviya hospital was opened, with 16 patients under dialysis six days a week. The consumables for this treatment cost around Rs. 5,000 per dialysis session, per patient. This dialysis unit was an initiative of Dr. Shamitha Dissanayake, a physician who was posted to Padaviya Hospital around two years ago. Dr. Dissanayake was recognised as the ‘Most Innovative Outstation Physician for 2013’ by the Ceylon College of Physicians for his ‘pioneering work in the area of CKDu patients’. The ‘X factor’ A recent study by a team from the Department of Pharmacology at the University of Raja Rata, has revealed a hypothesis that a herbicide used extensively in rice farming in Sri Lanka, ‘glyphosate,’ combines with other kidney toxic metals in the patient’s diet to morph into a glyphosate-metal combine which is ingested into the patient’s body and ultimately travels to the kidney, resulting in CKDu. This hypothesis has not been tested by any animal experimental studies or epidemiological research. Sri Lanka’s CKDu National Research Project Team in a recent report says that the study indicates multiple agents may play a role in afflicting patients with CKDu, including exposure to arsenic, cadmium, excess fluoride in ground water, genetic predisposition and association with farming and the extensive use of pesticides, etc. The link between glyphosate and CKDu is yet entirely theoretical. The speculation is that metals in hard water combined with some other unknown actor, a ‘compound X,’ may be the cause of CKDu. The hypothesis assumes that this ‘X factor’ must be an agricultural chemical which binds with heavy metals and results in an increased intake and retention of the heavy metals and the movement of such metals through the human system to the kidney. The metals accumulate in the kidney and induces malfunction of the organ and causes renal disease. As was stated earlier this is only a hypothesis, there is no clear evidence yet available of this link between glyphosate and CKDu. Ban on use of glyphosate Notwithstanding this lack of clear and categorical proof of the connection between glyphosate and CKDu, a ban on the use of glyphosate has been proposed. This is on the basis that although glyphosate is the most widely-used herbicide worldwide, most health studies have focused on the safety of glyphosate itself, rather than on the mixture of ingredients found in the weedicide containing glyphosate, with other factors. The so-called inert ingredients in the weedicide containing glyphosate could amplify the toxic effects on human cells even at concentrations much more diluted than those commonly used in rice growing areas. With his hypothesis staring us in our face, it is up to us to decide whether we should still continue allow the onward accumulation of glyphosate in our food supply, water resources and environment. Naturally from the side of the economic forces which market pesticides and weedicide, there has been, to say the least, an equal and opposite reaction to this talk of banning glyphosate. Glyphosate has a huge market in Sri Lanka’s rice bowl and in the tea plantations and is an extremely efficient weedicide which decimates weeds. The continual use of glyphosate-based weedicide will result in ground water being polluted in all parts of the islands, as the rivers starting from the central hills flow down in all directions of the compass to Sri Lanka plains, and the glyphosate used on the tea and rubber plantations will flow into all areas inhabited. The issue now raising its head in the Raja Rata and other rice bowl areas is due to glyphosate-based weedicide being extensively used in the rice farming. But the flow down from the tea plantations will affect all drinking water sources, all over Lanka in the long term. Notwithstanding this, soon after the Minister of Special Projects announced that the President had banned glyphosate-based weedicide, the Pesticide Technical Advisory Committee (PeTAC) gave publicity to the fact that they were making a request for an urgent meeting with the President and the Minister of agriculture to “discuss the controversy surrounding glyphosate, the active ingredient in the herbicide Roundup used by paddy farmers and the tea sector”. PeTAC argues that this so-called ban was based on a mere hypothesis (an unproven explanation) and that there was no established scientific data to prove that this agro chemical was the cause of kidney disease. A newspaper report, meanwhile, reported that at the Annual Academic Sessions of the Toxicology Society of Sri Lanka held recently, the general view was that although glyphosate is linked to organ toxicity, there is no direct or hard evidence to prove that it caused CKDu. The Director of Agricultural Services was reported in a newspaper report as stating that there was “no technological reason for the disuse of glyphosate as there was no sufficient scientific evidence to prove that it had caused renal ailments”. Position today So today, the position seems to be as follows. There is an unproven hypothesis that links glyphosate to CKDu. The weedicide Roundup is supposed to have been banned, but is yet said to be still available in the market. Glyphosate continues to be used in paddy fields, tea and rubber plantations. Young male rice farmers in our major rice growing areas are being decimated by CKDu. There are hardly any preventive steps being taken, except things like providing water filters to households, assisting households to harvest rain water, not a very common factor in our dry zone, where the main rice growing areas are located. Curative steps are very expensive, mostly unaffordable. Dialysis units are being established in hospitals in rice-growing areas. When a decisive step like the banning of glyphosate is announced, the weedicide sellers contest the decision. It looks as if this confused and irresponsible ‘policy paralysis’ situation will continue, with more and more young working age males being afflicted by CKDu, until the so-called scientific evidence is made available – like a dog or monkey or guinea pig, being fed with glyphosate and hard water and maybe some illicit liquor, in an experiment to prove the hypothesis on the connection between glyphosate and CKDu. Social stigma In the meantime, people are being afflicted by CKDu in increasing numbers, glyphosate is still being used, and billions are being spent on dialysis treatment. Analysts have estimated that an average of 13 young men may be dying a day due to CKDu. There is an out migration of young men from Sri Lanka’s rice bowl. Unfortunately, once a family member is afflicted with CKDu, and the neighbourhood community gets to know, there is a social stigma on the family. This is sad but true. There is a belief that CKDu is hereditary, which is unproven. Once a family member is diagnosed with CKDu, the whole extended family goes through economic hardship. The very thought of lifelong dialysis treatment causes mental and emotional depression. When the young male head of household, a rice farmer, is affected, other family members have to seek economic opportunities. Households and families break up; children have to stop their education. The social stigma results in even finding marriage partners being a difficulty. Other family members migrate to cities to avoid being stigmatised, seeking the anonymity of the urban environment. Employees of transferable services in Government and even private sector employees are reluctant to serve in CKDu-affected areas. Traditional old ‘Purana Gammana’ in the Raja Rata, the Sinhala heartland, and new settlements in the Land Settlement Scheme Colonies and the Mahaweli Scheme Colonies, are seeing an out migration of young males. The export of labour, especially women to West Asia as housemaids, exacerbates the issue. In time with the deployment of the armed services in these areas, cases of CKDu will inevitably appear among serving soldiers, sailors and airmen. International focus In the meantime, there has been an international focus on this issue. A group of Sri Lankan medical personnel and scientists working in the United States have written to the President of Sri Lanka requesting him to implement his decision to ban weedicide containing glyphosate. These scientists and medical men have urged that the burden is placed on special interest groups promoting glyphosate-based weedicide to prove the benign nature of the chemical that glyphosate combined with other factors found in Sri Lanka and are not injurious to human beings. They point out that the Presidential ban on glyphosate-based weedicide has not been implemented. Of course, Sri Lankans being what we are – similar to Noble Laureate Amartya Sen’s ‘Argumentative Indian’ – there is another point of view. A Lankan expatriate in Canada writes in querying these scientists’ claims and saying that in California glyphosate is freely available! The matter needs further study to firm up the hypothesis. Until then, the ban on glyphosate-based weedicide, while it can be done immediately, the effect on afflicting people with CKDu, will only be reduced in the long-term. Glyphosate would have leached into the water resource base of the rice-growing areas and will be flowing down from the tea and rubber plantations in the Central Hills. It will take decades to nullify the effect of the chemical. In the immediate effect provision of pure water is what can be done. Provision of water filters is one option. But there is a long-term maintenance aspect of the filter unit, which, even if the filter plant is donated, the local households, schools, communities and religious organisations may find these costs a burden in the medium and long term. Rain water harvesting, since the water is pure and unpolluted, is the best option. Financial incentives should be provided to households and institutions to set up the infrastructure. Special ‘hardship allowances’ should be paid to Government officials who volunteer to serve in CKDu-afflicted areas. The private sector can be given fiscal incentives. Unless the human resource and capacity is on location, no remedial program can work effectively. The example of one committed physician in Padaviya has been cited. Also education is the key. The causes of CKDu must be clearly communicated and clarified, to avoid social stigma and marginalisation. Doomsday predictions There are doomsday predictions, that the rice bowl area will be decimated of its young men, due to CKDu. That it will be a repeat of the effect of the Chola invasions on the Raja Rata kingdom in the days of yore, when the irrigation works which underpinned the Raja Rata hydraulic civilisation were destroyed, resulting in malaria getting a grip on the North Central and North East and the region being depopulated by the drift of the population to the South West. These grim predictions may not come to pass, provided that we overcome the present policy paralysis and some decisive action is taken, now, to meet the challenges faced by the people due to CKDu. The Colombo-centric policy making which has been the bane of this nation for so long and the allegedly current Southern-centric thinking clearly cannot provide adequate responses to CKDu nationwide – unless maybe the Walawa, Kirindi, Menik, Kumbukkan, Nilwala and Gin Gangas carry glyphosate residue to the south in their run-off waters from the tea and rubber plantations in Uva and Sabaragamuwa, which is in all probability already happening, to create a CKDu life-threatening situation in that region too. Then there might be some decisive action. But we cannot afford to wait. Paralysis is no policy. News is just out of a committee of bureaucrats chaired by the Secretary to the President, which has made 204 short and long term recommendations on this issue. The committee endorses an earlier recommendation by another expert team to prohibit certain agrochemicals, including glyphosate, which have been found in the ‘urinal residues of kidney patients’. The country yearns for action. (The writer is a lawyer, who has over 30 years of experience as a CEO in both State and private sectors. He retired from the office of Secretary, Ministry of Finance and currently is the Managing Director of the Sri Lanka Business Development Centre.)