Sri Lanka’s existing plague: Why are authorities mum on CKDU?

Wednesday, 21 May 2014 00:00 - - {{hitsCtrl.values.hits}}

By a Special Correspondent From 1990s-2014 what has happened so far? Chronic Kidney Disease of Unknown aetiology (CKDU) has plagued the farmers of the North Central Province of Sri Lanka since the 1990s. Analysts claim that thousands have died due to this dreaded disease and some estimate as many as two persons succumb to CKDU every day in Sri Lanka. It is high time that the medical community and the health authorities come up with some answers to this burning issue. Many hypotheses have been put forward by the learned people of Sri Lanka, as possible causes of CKDU. We have gone full circle from a hypothesis which first claimed that consumption of lotus roots and smoking tobacco could be the reason for CKDU in Sri Lanka, to consumption of thilapiya fish, to exposure to high fluoride content in water and then to possible exposure to aluminium fluoride.

"CKDU has plagued North Central Province farmers since the 1990s.
Analysts claim thousands have died due to CKDU – some estimate as many as two persons succumb to CKDU every day in Sri Lanka.
Media reports state 400,000 Sri Lankans in North Central and Uva Provinces are confirmed as CKDU patients.
Unconfirmed reports state that almost 22,000 deaths have occurred over the past 20 years in Anuradhapura District alone due to CKDU."

Since then, even more hypotheses have surfaced. Environmentalists and pressure groups now claim that exposure to arsenic and cadmium – found in pesticides – is the cause of CKDU, while some claim the disease is caused by cyanobacterial toxins. Today we are told that causes for CKDU are multi-factorial, as if it would help the poor patients and those who are prone to CKDU. Similar to the story of the court physician who carried out investigations on who had shot an arrow at the King instead of pulling the bolt out and treating the wound, the medical community and health authorities of the country have more or less taken their hands off finding a lasting solution to the CKDU issue. At least that is how it appears to be. Even though some work has been done by the medical community, silence in the midst of the mass hysteria created by some pressure groups makes everyone believe that medical researchers in this country are indifferent towards the CKDU issue. CKDU and research It is quite disheartening to note that despite CKDU being a national issue, there have been no studies conducted by our eminent scientists and medical research organisations until very recently (mid 2000). As in the case of many other issues in this country, there has been no conscious effort to collect data in a systematic manner and isolate factors while studying the problem in order to find solutions. The recent studies that have been conducted on the disease have been done by outside parties – one by Miyagi University Japan and the other by the World Health Organisation. The study that has been done on CKDU by the WHO is inconclusive, while there is much controversy surrounding it due to the colossal amount that was spent on the research. Root causes are yet to be identified and there is much ambiguity concerning the actual causes of the disease. So we have not gone very far from the 1990s, have we? The WHO Study According to media reports, approximately 400,000 Sri Lankans, between the ages 15 and 70, in the North Central and Uva Provinces are confirmed as CKDU patients. Do these numbers correspond to actual patients or those who enter hospital claiming that they have some sort of kidney problem? It cannot be stressed enough, the importance of working with valid and accurate data on this issue in order to find correlations between the disease and other factors including lifestyle, diet and exposure to environmental and occupational hazards. Furthermore, unconfirmed reports state that almost 22,000 deaths have occurred over the past 20 years in the Anuradhapura District alone due to CKDU. The media and pressure groups have highlighted this issue and have called upon authorities to take appropriate action to identify the causes and then treat the patients. The WHO study implies that 15% of the population in the two provinces is affected, while reports of the disease have been escalating in three other provinces – namely the North Western, Eastern and Southern Provinces, which were also identified as high risk areas. "The responsibility to find solutions to this grave health problem lies fair and square on the health authorities and the medical community. But why are they silent? Why are the studies that have already been done kept under lock and key? Have they identified the causes of CKDU as multi-factorial in nature? If so what are the factors and aren’t there qualified nephrologists in the country who could offer their services to find the answer? Are the health authorities making a genuine attempt to find the root causes of CKDU?" However, more questions have been raised concerning the WHO report due to the exorbitant cost of the study, the research design, methodology, sampling and the conclusions. There was no sociologist involved as part of the panel of experts, which in my opinion would have helped to interpret some of the key findings. Furthermore, there was no statistician who was part of the research team either. When we have the likes of Professor Thattil, who is one of most renowned statisticians in the region, one cannot understand why his expertise was not called upon to get a grip of the numbers and more importantly the meaning behind the statistics in order to understand the trends. Once again I feel an indifferent medical community that has not challenged these findings has also failed to be a part of the public discourse on the subject. Other research on CKDU One must commend Professor O.A. Illeperuma, Professor S. Bandara and Dr. Dhammika Menike of the University of Peradeniya and Dr. K. Wanigasuriya of University of Sri Jayawardenapura among many others who have worked tirelessly in recent times to search for answers and test hypotheses regarding this deadly disease. In 2005, Professor Illeperuma addressed the hypothesis that CKDU is caused by high fluoride and possible exposure to aluminium fluoride. Unfortunately it does not explain the geographical distribution of the disease. In 2007 Professor Bandara claimed that excessive intake of cadmium, which could have entered the body through food sources, may be the cause of CKDU. However, in 2010 Professor Chandrajith revealed through his tests that cadmium is not the cause. That year, Dr. Dhammika Menike proposed that cyanobacterial toxins could be the root cause of CKDU while as far back as 2007 Dr. Kamini Wanigasooriya identified a major risk factor which later turned to popular belief – pesticide-using farmers who consume well water. These theories were somewhat contradicted in 2011 by Professor M. Amarasinghe, who pointed out that 87% of the population in CKDU-prone areas use tube wells or well water while the presence of cyanobacteria in those water sources was negligible. So who shot the arrow at the King in this case? We may have been moving in a clear direction looking for answers though now we seem to have been derailed by the mass-hysteria created by various pressure groups who have put forward culprits or even scapegoats without any empirical evidence. In 2006, The Ceylon Medical Journal published research findings on ‘Exposure to acetyl cholinesterase-inhibiting pesticides and chronic renal failure’. The objective was to determine if there is an association between chronic renal failure (CRF) and low-level organophosphate (OP) pesticide exposure (R.J. Peiris-John, J.K.P. Wanigasuriya, A.R. Wickremasinghe, W.P. Dissanayake, A. Hittarage). However, the study could not conclude or elicit whether it was indeed OP exposure that caused the disease. It was noted that further in-depth epidemiological studies were required. Further studies to evaluate risk factors revealed that the disease is triggered by an environmental factor in those who are genetically predisposed. According to the findings, scientists in Sri Lanka are now certain that there is familial tendency to have chronic kidney diseases though it is not hereditary. At the 45th Annual Academic Sessions of the Ceylon College of Physicians (2012), the Conclusions of an Evaluation of Urinary Biomarkers and Environmental Metal Exposure in patients with CKDU was presented. What had come out of the study was that both the CKDU and control subjects from the NCP show evidence of chronic exposure to heavy metals. Furthermore it was seen that there may be other environmental factors making the NCP farmers more susceptible to kidney damage while agrochemical use could be a contributing factor for the heavy metal exposure. So was it just one culprit who shot the arrow? Or could it have been many conspirators who shot several bolts? Responsibility of health authorities and medical community The responsibility to find solutions to this grave health problem lies fair and square on the health authorities and the medical community. But why are they silent? Why are the studies that have already been done kept under lock and key? Have they identified the causes of CKDU as multi-factorial in nature? If so what are the factors and aren’t there qualified nephrologists in the country who could offer their services to find the answer? Are the health authorities making a genuine attempt to find the root causes of CKDU? Experts say that in many cases they have found that in selected villages there are farmers who lead similar lifestyles and consume the same water as the CKDU patients but have not contracted the disease. Therefore, there are definite questions to be asked about susceptibility. Furthermore, there is no known genetic research done to study the farmers who are suffering from CKDU in the midst of a community that seemed to have developed a resistance to the disease. Another question that has to be asked is whether the health authorities have studied the biomarkers relating to CKDU. Biomarkers are biological measures of a biological state and show distinct characteristics that can be objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes or pharmacological responses to a therapeutic intervention. Biomarkers are the measures used to perform clinical assessments on blood pressure or cholesterol levels and are used to monitor and predict health states in individuals or across populations so that appropriate therapeutic intervention can be planned. Even after 20 years of CKDU, sufficient studies have not been carried out on biomarkers to understand the disease. Where do we go from here? Much time has been lost already and thousands have perished as a result of CKDU. The medical and scientific communities must join hands to isolate factors and study the effects of the environment on animal species to discover root causes of CKDU. Those who are vulnerable and susceptible to the disease as well as those who have developed a resistance to the disease must be studied extensively. The Medical Research Institute (MRI) of Sri Lanka has the capacity and capability to carry out multi-disciplinary research concerning CKDU. The only constraining factor could be the lack of funds. It is not too late even now to fund such a study conducted by a responsible organisation that could take leadership in this matter and find solutions to CKDU. Perhaps the answer lies there. I don’t claim to have the answers and I am neither a scientist nor a medical researcher. I am only a concerned citizen and I am not sure whether the relevant authorities are currently making a conscious and genuine effort to find answers for CKDU.