Echelon July 2015 column: Kidney Disease Needs ‘Heart and Mind’ solutions

Text of my column written for Echelon monthly business magazine, Sri Lanka, July 2015 issue

Kidney Disease Needs ‘Heart and Mind’ solutions

 By Nalaka Gunawardene

Mass kidney failure in Sri Lanka is a sign of wider systemic failure in land and water care

Mass kidney failure in Sri Lanka is a sign of wider systemic failure in land and water care

If bans and prohibitions were a measure of good governance, Sri Lanka would probably score well in global rankings. Successive governments have shown a penchant for banning – usually without much evidence or debate.

The latest such ban concerns glyphosate — the world’s most widely used herbicide – on the basis that it was causing chronic kidney disease in parts of the Dry Zone.

First, President Maithripala Sirisena announced such a ban in late May (which earned him lots of favourable coverage in environmental and health related websites worldwide).

Then, on 29 May 2015, state-owned Daily News reported under Cabinet decisions: “The scientists who carry out research on renal diseases prevailing in many parts of the country have pointed out that the use of pesticides, weedicides and chemical fertiliser could be contributing to this situation. Accordingly the government has already banned the import and usage of four identified chemical fertilizer and pesticides. In addition to this President has decided to totally ban the import and usage of glyphosate.”

Finally, the Finance Ministry on 11 June gazetted regulations banning the import of glyphosate under the Import and Export (Control) Act. By mid June, it was still unclear whether the ban is comprehensive, or an exception is to be made for tea plantations that rely heavily on this weedicide in lieu of costly labour for manual weeding.

Has this decision tackled the massive public health and humanitarian crisis caused by mass kidney failure? Sadly, no. The new government has ignored the views of a vast majority of Lankan scientists, and sided with an unproven hypothesis. This undermines evidence-based policy making and allows activist rhetoric to decide affairs of the state.

 A Silent Emergency

Map showing distribution of CKDu in Sri Lanka. Source - Journal of Agricultural Sciences, Sri Lanka http://jas.sljol.info/articles/abstract/10.4038/jas.v10i2.8055/

Map showing distribution of CKDu in Sri Lanka. Source – Journal of Agricultural Sciences, Sri Lanka http://jas.sljol.info/articles/abstract/10.4038/jas.v10i2.8055/

The chronic kidney disease was first reported from certain parts of the Dry Zone in the early 1990s. Hundreds were diagnosed with kidney failure – but none had the common risk factors of diabetes, high blood pressure or obesity. Hence the official name: Chronic Kidney Disease of uncertain aetiology, or CKDu.

The disease built up stealthily in the body, manifesting only in advanced stages. By then, regular dialysis or transplants were the only treatment options. Most affected were male farmers in working age, between 30 and 60 years.

In early 2013, the Ministry of Health estimated that some 450,000 persons were affected. The cumulative death toll has been reported between 20,000 and 22,000, but these numbers are not verified.

The kidney specialist who first detected the disease worries that some activists are exaggerating CKDu numbers. Dr Tilak Abeysekera, who heads the department of nephrology and transplantation at the Kandy Teaching Hospital, underlines the critical need for correct diagnosis. CKDu should not be confused with regular types of kidney disease, he says.

In December 2013, he told a national symposium organised by the National Academy of Sciences of Sri Lanka (NASSL) that only 16% of kidney patients in the Anuradhapura district – ‘ground zero’ of the mystery disease – could be classified as having CKDu.

It is clear, however, that CKDu has become a national humanitarian emergency. Providing medication and dialysis for those living with CKDu already costs more than 5% of the country’s annual health budget. With each dialysis session costing around LKR 12,000 (and 3 or 4 needed every week), very few among the affected can afford private healthcare.

Besides the mounting humanitarian cost, CKDu also has implications for agricultural productivity and rural economies as more farmers are stricken. With the cause as yet unknown (although confirmed as non-communicable), fears, myths and stigma are also spreading.

Looking for Causes

For two decades, researchers in Sri Lanka and their overseas collaborators have been investigating various environmental, geochemical and lifestyle-related factors. They have come up with a dozen hypotheses, none of it proven as yet.

Among the environmental factors suspected are: naturally high levels of Fluoride in groundwater; use of Aluminium utensils with such water; naturally occurring hard water (with high mineral content); cyanobacterial toxins in water; pesticide residues; and higher than safe levels of Cadmium or Arsenic. Lifestyle factors studied include the locally brewed liquor (kasippu), and certain Ayurvedic medicinal concoctions. Genetic predisposition to kidney failure has also been probed in some areas.

Researchers are baffled why CKDu is found only in certain areas of the Dry Zone when these environmental and lifestyle factors are common to a much larger segment of population. This makes it much harder to pinpoint a specific cause.

The most comprehensive study to date, the National CKDu Research Project (2009-2011), concluded that CKDu results from not one but several causes. The multidisciplinary study, led by Ministry of Health with support from the World Health Organisation (WHO), highlighted several risk factors. These include long-term exposure to low levels of cadmium and arsenic through the food chain, which are linked to the wide use of chemical fertilisers and pesticides. Selenium deficiency in the diet and genetic susceptibility might also play a part, the study found.

These findings were academically published in BMC Nephrology journal in August 2013 (See: www.biomedcentral.com/1471-2369/14/180). The paper ended with these words: “Steps are being taken to strengthen the water supply scheme in the endemic area as well as the regulations related to procurement and distribution of fertilizers and pesticides. Further studies are ongoing to investigate the contributory role of infections in the pathogenesis of CKDu.”

 Hazards of Pseudoscience

One thing is clear. Remedial or precautionary measures cannot be delayed until a full understanding of the disease emerges. Indeed, WHO has recommended taking care of the affected while science takes its own course.

Dr Shanthi Mendis, WHO’s director for managing non-communicable diseases, says: “CKDu is a major public health issue placing a heavy burden on government health expenditure and is a cause of catastrophic expenditure for families, leading to poverty and stigma in the community.”

CKDu needs a well-coordinated response from public health, agriculture and water supply sectors that typically fall under separate government ministries and agencies. We need to see mass kidney failure as more than just a public health emergency or environmental crisis. It is a sign of cascading policy failures in land care, water management and farming over decades.

In such complex situations, looking for a single ‘villain’ is both simplistic and misleading. For sure, the double-edged legacy of the Green Revolution — which promoted high external inputs in agriculture — must be critiqued, and past policy blunders need correction. Yet knee-jerk reactions or patchy regulation can do more harm than good.

“In Sri Lanka we have a powerful lobby of pseudoscientists who seek cheap popularity by claiming to work against the multinational corporations for their own vested political interests,” says Dr Oliver A Ileperuma, a senior professor of chemistry at Peradeniya University. In his view, the recent glyphosate ban is a pure political decision without any scientific basis.

His concerns are shared by several hundred eminent Lankan scientists who are fellows of NASSL, an independent scientific body (not a state agency). The Academy said in a statement in mid June that it was “not aware of any scientific evidence from studies in Sri Lanka or abroad showing that CKDu is caused by glyphosate.”

NASSL President Prof Vijaya Kumar said: “The very limited information available on glyphosate in Sri Lanka does not show that levels of glyphosate in drinking water in CKDu affected areas (North Central Province) are above the international standards set for safety. CKDu is rarely reported among farmers in neighbouring areas such as Ampara, Puttlam and Jaffna or even the wet zone, where glyphosate is used to similar extent. It has also not been reported in tea growing areas where glyphosate is far more intensively used.”

Agrochemical regulation

In recent years, the search for CKDu causes has become too mixed up with the separate case for tighter regulation of agrochemicals, a policy need on its own merit. International experience shows that a sectoral approach works better than a chemical by chemical one.

The bottomline: improving Sri Lanka’s agrochemical regulation needs an evidence-based, rigorous process that does not jeopardize the country’s food security or farmers’ livelihoods. A gradual shift to organic farming (currently practiced on less than 2% of our farmland) is ideal, but can take decades to accomplish.

Our health and environmental activists must rise above their demonise-and-ban approaches to grasp the bigger picture. They can do better than ridiculing senior scientists who don’t support populist notions. Effective policy advocacy in today’s world requires problem solving and collaboration – not conspiracy theories or confrontation.

Hijacking a human tragedy like CKDu for scoring cheap debating points is not worthy of any true activist or politician.

Proceedings of Dec 2013 NAASL National Symposium on CKDu are at: http://nas-srilanka.org/?page_id=1145

Science writer Nalaka Gunawardene is on Twitter @NalakaG and blogs at http://nalakagunawardene.com

Advertisements

Don’t exaggerate Lanka’s kidney disease, its discoverer pleads

Feature article published in Ceylon Today newspaper,  28 Dec 2013

Don’t exaggerate Lanka’s kidney disease, its discoverer pleads

 By Nalaka Gunawardene

See also: Science and Politics of Mass Kidney Failure in Sri Lanka, Groundviews.org, 19 Aug 2012

Image courtesy Down to Earth magazine, India

Image courtesy Down to Earth magazine, India

While unexplained mass kidney failure is a serious public health problem in Sri Lanka, some persons are exaggerating the number of cases and deaths resulting from it, says the kidney specialist who first detected the disease.

Consultant Nephrologist Dr Tilak Abeysekera, who heads the Department of Nephrology and Transplantation at the Teaching Hospital Kandy, told a recent scientific meeting that it is very important to correctly diagnose the ailment – and not get it mixed up with other types of kidney disease.

“For example, only 16% of kidney patients in the Anuradhapura district can be classified as affected by what is now called Chronic Kidney Disease of unknown aetiology, or CKDu,” he said. He was speaking at a national symposium organised by the National Academy of Sciences of Sri Lanka (NASSL).

The symposium, held in Colombo on 10 December 2013, brought together senior representatives from many public institutions, research organisations and advocacy groups. It discussed the current status of knowledge of the disease, its occurrence, cause(s) and the short and long-term action needed to combat or mitigate it.

Wide-ranging discussions at the symposium highlighted the need for better disease surveillance, and further research. Participants also agreed on the need for much caution by policy makers and the media to avoid creating panic and confusion.

“Some writers to newspapers have claimed that the kidney disease is worse than the (2004) tsunami. The two tragedies are not comparable, and many numbers being mentioned in the media are gross exaggerations,” Dr Abeysekera said.

 Mystery disease

CKDu emerged in the early 1990s, when hundreds of people in Sri Lanka’s Dry Zone – heartland of its farming — developed kidney failure without having the common causative factors of diabetes or high blood pressure.

Most affected were men aged between 30 and 60 years who worked as farmers. The disease built up inside the body without tell-tale signs or symptoms, manifesting only in advanced stages.

Dr Abeysekera was the first to notice and report this variation of the disease that had no immediately apparent cause. As the numbers rose, doctors and other scientists began probing further, trying to identify factors that triggered kidney failure.

Having first appeared in the North Central Province, CKDu has since been reported from parts of five more provinces: the North Western, Uva, Eastern, Central and Northern. The endemic area now covers around 17,000 square km, which is home to over 2.5 million people. To date, it remains exclusively a Dry Zone disease.

Owing to discrepancies in record keeping, it is difficult to arrive at a reliable estimate of deaths resulting from CKDu, According to Dr. Kingsley de Alwis, President of NASSL, deaths have variously been estimated at between 20,000 and 22,000 over the past 20 years. These numbers are not fully verified.

According to him, some 8,000 persons are currently undergoing treatment. This costs the public health sector over Rs. 4,000 million every year.

Over the years, many scientific studies have been carried out and various environmental, geochemical and lifestyle related factors have been probed. Researchers now suspect environmental and genetic factors as causes – but a definitive link to a specific factor has yet to be found.

The National CKDu research project, initiated and led by the Ministry of Health during 2009-2011, has concluded that CKDu is caused by multiple factors instead of a single one (see also box below).

In particular, it found chronic exposure of people in the endemic area to low levels of Cadmium through the food chain and also to pesticides. It also reported a genetic susceptibility in individuals with CKDu.

 Many causes

Dr Shanthi Mendis, Director, Management of Non-communicable Diseases at WHO, told the symposium that kidney disease due to environmental factors is not unique to Sri Lanka. It has also been reported from Japan, Nicaragua, El Salvador, Croatia, Bulgaria and Serbia among others.

In Sri Lanka, WHO-supported research has shown that men over 39 years of age who are engaged in chena cultivation are more prone to CKDu. A positive family history in parents or siblings also increases the risk.

According to Dr Mendis, among the factors that appear to play a role are: chronic exposure to low levels of Cadmium through the food chain; exposure to nephrotoxic (kidney-damaging) pesticides; concurrent exposure to other heavy metals (Arsenic and Lead); deficiency of Selenium in diet; genetic susceptibility to kidney failure; and the use of Ayurvedic herbal remedies containing the Sapsanda plant (Aristolochia indica).

Cadmium enters the environment mainly through chemical fertilisers. The national research project did not find drinking water as a main source of Cadmium.

“In endemic areas, high Cadmium levels were found in certain vegetables such as lotus roots, freshwater fish and tobacco. But Cadmium in rice in both endemic and nonendemic areas was less than the allowable limit of 0.2 milligrams per kilogram,” Dr Mendis said.

Traces of Fluoride and Calcium naturally occurring in groundwater may also aggravate the effect of nephrotoxins and contribute to CKDu, she added.

Agrochemicals are not the only substances to watch. Dr Mendis also highlighted 66 Ayurvedic medicinal prescriptions that contain Aristolochia, being used for treating over 20 ailments. These include remedies for snakebite, fever, body pains, labour pain, indigestion and headache. Most people have no idea what their medicine contains, making it particularly difficult to assess exposure to this factor.

As often happens, research has raised more questions while clarifying some issues. Further studies are needed to understand exactly how certain plants accumulate heavy metals from their surroundings.

According to NASSL President Dr de Alwis, this is the typical process of science. “We need not be unduly alarmed about the number of different causes to which CKDu is attributed by scientists…Science works through a series of interactions, as well as the clash of ideas.”

Dr Tissa Vitarana, Senior Minister of Scientific Affairs who opened the symposium, asked all researchers to keep an open mind in such scientific investigations, ensure rigour of testing and analyis, and discuss their findings widely.

“There has been a spate of media abuse on CKDu. I’m glad to note that the media hype has died down so that a more sensible evaluation becomes possible,” he said.

Dr Vitarana, who is a virologist by training, added: “Cadmium, the main heavy metal suspected of being responsible for CKDu, enters our environment mainly through chemical fertilisers. There is no argument that we need to reduce use of such fertilisers. But as a scientist, I need to be convinced that Cadmium is the main cause. Right now, there is no such conclusive evidence, so we need to keep an open mind.”

Remedies & prevention

While the debate on exact causes of CKDu continues in scientific circles, the public health toll keeps rising.

“CKDu is a major public health issue placing a heavy burden on Government health expenditure and is a cause of catastrophic expenditure for individuals and families leading to poverty and stigma in the community,” WHO’s Dr Mendis said.

And as Minister Vitarana noted, in affected areas of the Dry Zone, farmers’ morale is breaking down. “This can raise questions on the future of farming in Sri Lanka.”

Based on the National CKDu research project, WHO has recommended a number of short and long term actions for ministries and other state agencies concerned with health, water supply, food and agriculture sectors.

An urgent priority is to supply clean drinking water to all people living in the endemic districts. Most people currently rely on groundwater, tapped through tube wells, hand pumps, or dug wells. The government’s 2014 budget proposals have recently allocated Rs 900 million to set up Reverse Osmosis small treatment plants that can purify ground water at local level.

Meanwhile, acting on other recommendations, the Ministry of Health has intensified public education and CKDu surveillance.  At the same time, more treatment facilities – including kidney dialysis units – are being set up.

Many families of patients living with CKDu face economic hardship as their breadwinner can no longer work. They need both livelihood and counselling support.

On the preventive front, the Health Ministry now advises against consuming lotus roots in endemic areas, and asks people to be careful with all herbal medicines containing Sapsanda. One study recommendation is for regulating the use of nephrotoxic herbal medicines.

The national research study has also recommended action for stricter regulation of agrochemicals. It specifically calls for regulating the indiscriminate use of synthetic fertilisers, in particular phosphate fertilisers containing traces of Cadmium, Arsenic and Lead. Farmer reliance on these can be reduced by greater use of locally made rock phosphate. Similarly, better regulation of pesticide distribution and use is also needed.

Going a step further, the study has advocated strengthening tobacco regulation to protect people from exposure to Cadmium through passive smoking. This should add to the already strong case against tobacco.

The humanitarian crisis of CKDu has reached such levels, notes WHO, that urgent remedial actions are needed even as researchers continue their investigations.

“Translating available research findings into action should not be delayed. Implementing multisectoral measures to people’s (especially children’s) exposure to nephrotoxins is a top priority,” said Dr Mendis. “Follow-up research should not be a barrier for implementing WHO recommendations.”

Text box:

 It was a national study, clarifies Health Ministry

The national research project on CKDu was co-funded by the World Health Organization (WHO) and Sri Lanka National Science Foundation (NSF). Comprising 11 studies, it is most comprehensive investigation on the topic so far, and involved dozens of local researchers and senior public health officials.

Research teams measured arsenic, cadmium, lead, selenium, pesticides and other elements, often linked with kidney failure, in biological samples from CKDu patients from three endemic areas (Anuradhapura, Polonnaruwa and Badulla). They compared the data with control groups from the endemic areas and a non-endemic area, i.e. Hambantota. They also analysed food, water, soil and agrochemicals from all the areas for the presence of heavy metals such as Cadmium, Arsenic and Lead.

The research findings were formally released in mid 2013. They were also published as a scientific paper in the international medical journal BMC Nephrology in August 2013. The full paper can be accessed free online at: http://www.biomedcentral.com/1471-2369/14/180

“This is a national study carried out by our own experts, with World Health Organization (WHO) providing technical advice and part of the funding,” said Dr P.G. Mahipala, Director General of Health Services at the Ministry of Health.

He clarified: “It is not correct to refer to this study as a WHO study.”

Don’t exaggerate Lanka’s kidney disease - by Nalaka Gunawardene - Ceylon Today, 28 Dec 2013

Don’t exaggerate Lanka’s kidney disease – by Nalaka Gunawardene – Ceylon Today, 28 Dec 2013