CKDu seems to be a complex problem, but scientists opine that solutions will be simple if people are educated
A cross-section of the nation’s scientists gathered at Galadari Hotel, Colombo, on December 10 (Tuesday), to discuss Chronic Kidney Disease of Uncertain (CKDU) Aetiology – a major health problem afflicting farming communities in the ‘dry zone’. The event was organized by the National Academy of Sciences of Sri Lanka with the specific objective of arriving at a scientific basis for future action.
In this article we bring you the summary of the discussions at this symposium.
First diagnosed in the early 1990s at Anuradhapura Hospital, CKDu has now become the most serious health problem afflicting farming communities in many ‘dry zone’ areas. It has already been detected in six of the nine provinces in the country.
Common features of affected villages (endemic areas) and CKDu patients
– These villages tend to be clustered around dry zone ‘tanks’ (reservoirs) and irrigation canals.
– Population mainly engaged in farming (rice/paddy farmers)
– Low socio-economic status appears to be a distinguishing feature of many CKDu patients.
– Disease begins to appear in older people. Most affected age group -45-60yrs.
– More men than women affected by disease. Men outnumber women by a factor of 2.5
– Alcohol consumption (illicit brew-“kassipu”) high among men.
– People obtain drinking water mainly from open (dug) wells. This water tends to have a high content of fluoride (2-5 parts per million – ppm). ‘Hardness’ (due to dissolved Calcium and Magnesium salts) also appears to be a common characteristic of such water.
– Analysis of drinking water has NOT shown high levels (above WHO recommended safety levels) for heavy metals such as cadmium, arsenic, lead etc.
CKDu is estimated to have accounted for the deaths of approximately 20 -22,000 people over the past two decades. There is very little hope for people suffering from the disease. By the time clinical symptoms appear, the kidneys have already been seriously damaged. Only a kidney transplant will enable patients to lead a relatively normal life. Frequent dialysis (once every three days) may help prolong life, but this is troublesome and expensive.
The social and economic costs of CKDu to patients, their families, and the National health budget are staggering. The illness has a direct impact on patients’ daily life including livelihood activities, domestic tasks, consumption patterns and their participation in social activities at community level. As the disease advances, patients become too ill to continue in gainful employment, and, as the most vulnerable individuals tend to be middle-aged men, many families are deprived of their principal ‘bread winner’. Families affected by CKDu are pathetic – driven to despair and impoverishment. In some families more than one person may be affected by the disease. Children drop out of school, and seek employment to keep the home fires burning.
The Ministry of Health is stretched to the utmost in trying to cope with widespread occurrence of CKDu in the country. A single round of dialysis (taking about four hours) costs the government approximately 7,500 rupees. The bare minimum cost incurred by the government in treating a single patient with dialysis amounts to a staggering 100,000 rupees a month.
Nephrology units located in government hospitals are severely strained as a result of shortage of dialysis machines. It is estimated that the country needs at least 1700 dialysis machines to meet present demand, but the number available at government hospitals amounts to only about 76. Each machine costs approximately two million rupees, and additional funds are needed for regular servicing and maintenance of this equipment.
The Ministry of Health spends 350-400 million rupees annually for management of renal disease (dialysis, transplants etc.). About 2000 new patients seek treatment for end stage renal disease each year.The loss in financial terms to the labor force defies accurate quantification. However, it has been estimated at Rupees 1,035,000 in Medawachchiya and 445,000 in Padaviya.
Despite over two decades of research, by scientists both local and foreign, the exact cause of the disease is still unknown. Available evidence indicates that the disease is a multifactorial, environmentally acquired disease.
Because its exact cause is still uncertain, no specific action can be prescribed for its prevention. However, there seems to be widespread consensus among scientists that improving quality of drinking water, preventing excessive use of fertilizers and pesticides and health education in CKDu endemic areas may help substantially in preventing, or delaying the onset of the disease.
Considering the complexity, magnitude and gravity of the CKDu problem, investigations and action programs must not only be multidisciplinary, but also multisectoral involving Government Departments/agencies, Non Governmental Organizations(NGO), Private sector and Civil Society groups. The role that NGOs could play should not be underestimated (since they have proven experience in working with underprivileged rural communities in areas such as health education, water supply and sanitation projects, rural extension etc). As such, active participation of NGOs and CBOs must be an integral part of future programs designed to address the CKDu problem.
Proposed interventions must consider the specific context of CKDu affected communities – widely scattered rural households in the dry zone; essentially poor farmers having limited access to public services (health education, water supply and sanitation, agricultural extension ); dilapidated roads, relatively low educational level etc.
The need to improve the quality of drinking water in CKDu endemic areas is widely recognized and accepted as an issue deserving the highest priority in preventing CKDu. However, there seems to be considerable disagreement on how this can be best accomplished. Several organizations (Water Supply and Drainage Board, bilateral assistance programs, and Nongovernmental organizations) have already attempted to provide improved water quality to residents in some areas through use of water filters(Electro-chemical coagulation units, Reverse Osmosis systems) and rainwater harvesting and storage structures. Despite these laudable efforts, community response with respect to utilization of these facilities is believed to be poor. It is thus apparent that the reasons for lack of community interest in these interventions be ascertained before prescribing the same facilities for adoption in other areas of the country. The urgency of undertaking such study becomes more apparent in the light of H.E. the President’s recent Budget speech allocating a substantial sum of money (900 million SLR ?) for provision of water filters to dry zone villagers.
Evaluate existing water purification facilities
An investigation of this nature will provide a sound, rational basis for installing appropriate water purification facilities.
This evaluation needs to focus on the following issues:
(i) Determine the technical effectiveness of installed water purification facilities at village level.
(ii) Determine ability of installed facilities to meet community and household water requirements.
(iii) Determine community and householders’ response/attitudes to drinking rainwater and filtered water.
(iv) Identify weaknesses/bottlenecks in operating the facilities at community level.
Recommend the most viable, cost effective, and sustainable water purification method acceptable to a wide spectrum of communities in CKDu endemic areas.
Use and careless handling of inorganic fertilizers and pesticides by farmers have contributed to many environmental pollution problems (contamination of ground water, eutrophication (nutrient enrichment) of reservoirs leading to algal blooms) in recent years. This unhealthy situation is due to several factors: (i). Ineffectiveness and impotency of the Agriculture Department’s extension services (II) Aggressive advertising of pesticides by chemical companies and their local agents. (III) Inadequate safeguards and regulatory measures pertaining to the import of highly toxic chemicals into the country and (IV). Huge fertilizer subsidy (amounting to over 90% at one stage) enabling farmers to resort to excessive application of cheap fertilizers.
Effective action has already been initiated by the Department of Agriculture to curb advertisements pertaining to pesticides as well as banning the import of some pesticides (Carbaryl, Chloropyrifos, Propanil and Carbofuran), in addition to strengthening regulatory mechanisms applicable to pesticide imports. Fertilizer prices have been increased by the government recently in an effort to curb excessive fertilizer application. However, there is no likelihood of any significant improvement in public sector extension services in the foreseeable future. This void needs to be filled by NGOs and CBOs.
Cosmetic and ill conceived changes to this country’s agricultural extension services over the past two decades have resulted in this vital service being rendered completely impotent. Devolving extension functions to Provincial Councils, in 1987 has further compounded the problem.
Any realistic effort to solve weaknesses in the extension services would require a Government – NGO partnership, and training and deploying farmers as community based farmer extensionists. This does NOT mean the creation of another cadre of public servants, but enlisting the services of farmers on a voluntary basis, for a specific purpose/s (awareness raising and educating fellow farmers on rational application of pesticides and fertilizer). These farmer extensionists (‘Praja Sevaka’) may be provided a modest incentive allowance for their services). Such innovative steps (“out of the box thinking”) are urgently required, at least in CKDu endemic areas, in preventing excessive use and indiscriminate application of pesticides by farmers.
An effective community health education program designed to inform rural households on the importance of drinking adequate quantities of water (at least 3- 4 liters/adult/day); refraining from smoking, intake of illicit brews (Kassippu), avoiding self medication by rushing to the nearest pharmacy or village Kade to purchase strong analgesics (pain killers) for relief of common body aches and pains, and overall improved nutrition is a vital need for residents in CKDu endemic areas. Educating school children on the above issues may help in getting the message across to their parents.
Well organized and effective community mobilization programs need to be carried out in CKDU endemic villages before disbursing any benefits (like water purification facilities) to the community. Trained community mobilizers deployed by suitable NGOs/CBOs will use participatory rural appraisal tools such as social mapping, seasonal charts, transect walks, key informant interviews and focus group discussions in accomplishing this task.
Main purpose of this exercise is twofold: (i) Encourage villagers to reflect on, discuss and analyze their situation and activities, life style, food habits, drinking water sources (water quality) ,health related problems – incidence of disease (CKDu) and others, health education, health care and medication; farming systems (with special emphasis on fertilizer and pesticide use), availability of extension services, content of extension messages etc. and (ii) Enable ‘outsiders’ ( Researchers, Administrative officers and NGO personnel) to obtain a thorough understanding of the specific village situation.
The author is a member of the CKDu Research Group, Kandy. He holds a Masters’ degree in Agriculture from the University of the Philippines, and has over 30years experience in tropical agriculture and rural development in South and South-East Asia (Sri Lanka, Maldives, Philippines and Laos.)He has also been a dry zone farmer himself for ten years. He is currently based in Kandy, Sri Lanka, and functions as a free lance consultant in sustainable agriculture and rural development.He may be contacted at the following e-mail address: