INDIA AND CHRONIC KIDNEY DISEASE Comment

Quadrants of a renal quandary

An unusually high incidence of the disease is common to four regions in Goa, Maharashtra, Odisha and Andhra Pradesh. While area-specific studies have thrown up possible reasons, the lone scientific study proposed to connect the dots is stuck for funding

It’s a health puzzle waiting to be solved. For over two decades, pockets of farmlands in four different corners of the country have reported a high prevalence of chronic kidney disease (CKD). The cause of the malady, which is otherwise linked to diabetes and hypertension in individual cases, remains undefined in these four areas where it has been observed in clusters.

Doctors in Canacona taluka of South Goa, Narasinghpur block in Cuttack district of Odisha, villages along the Purna river in the Buldhana-Akola-Amravati belt in Maharashtra and the coconut plantation-rich Uddanam area in Srikakulam district of Andhra Pradesh have for years been reporting an unusually high number of CKD cases, with surveys pointing at contamination of groundwater as a possible cause.

Making the connections

These surveys could be highlighting a serious concern, but have remained limited in their scope, with only a few dialysis centres or kidney check-up camps in the affected villages. The lone scientific study proposed to connect the dots is stuck for funding.

Doctors in Uddanam, bordering Odisha, had been reporting a high incidence of CKD for the last 15 years, a concern big enough for the State’s health officials to seek a proper survey. “We wanted to establish a reason,” says Dr. T. Ravi Raju, former Director of Medical Education in Andhra Pradesh and currently vice-chancellor of Dr. NTR University of Health Sciences in Vijayawada. He says the affected people are agricultural workers working in coconut plantations. “The issue was even raised in the Assembly. The point is, we also need to establish if the prevalence is indeed high,” says Dr. Raju. He, however, does go on to estimate a 25-30 per cent prevalence of CKD in Uddanam (as against the 7-10 per cent prevalence in the country), but then again,there is no proper scientific data to corroborate it, he adds.



Over a thousand miles from Srikakulam, located on the western coast is Canacona, where the prevalence of CKD since the late 1980s led to a survey by the State government and the National Institute of Occupational Health in 2005-06 that studied the presence of heavy metals in drinking water, fish, soil and blood samples. The study had found clinical similarities between Balkan Endemic Nephropathy — a familial, chronic renal disease — and the CKD cases in Canacona. It noted that the level of Ochratoxin A, a food-contaminating fungi metabolite, was found to be higher among people who suffered from the condition, like it did in the Balkans. A decade later, doctors in Goa are still unsure of what is causing the disease. “People who were born in Canacona but migrated to other parts have the same type of disease,” says Dr. Shital Lengade, consultant nephrologist with Apollo Hospitals in Goa. Another study was carried out by the Goa Medical College (GMC), but nothing conclusive was found, says Dr. J.P. Tiwari, head of the Department of Nephrology at GMC. The Goa government has since opened dialysis centres in the area.



Dialysis centres have also come up in Jalgaon (Jamod), Sangrampur and Shegaon talukas of Buldhana district of Maharashtra. Here, local MLA Dr. Sanjay Kute holds kidney check-up camps and has installed reverse osmosis units following a survey which confirmed a long-held belief that the area’s soil quality is leading to higher salinity in water.

“The soil is impervious so water doesn’t percolate, preventing groundwater recharge. And this leads to high salinity,” says Dr. Praveen Kathane, senior geologist with Groundwater Surveys and Development Agency, Buldhana, who was part of the survey. He said the concentration of total dissolved solids in the water was found to be as high as 9,000 ppm (parts per million) in some parts when the desirable limit is 1,500 ppm. Independent experts, however, question if high salinity causes CKD. The kidney concern in Odisha’s Narasinghpur and Baramba blocks had led the State government to ask the regional medical research centre of the Indian Council of Medical Research (ICMR) in Bhubaneswar to conduct a survey. The ICMR team mapped the villages and carried out a door-to-door census, and proposed further investigation. Last year, the State Health Department undertook another survey and found 572 cases of CKD in Narasinghpur block. Water contamination, officials noted, was possibly the reason. But then they hit another roadblock.

“Only men in the 30-55 age group were affected, but not children, women and senior citizens,” says Dr. P.K.B. Patnaik, Joint Director, Non-Communicable Diseases cell, Odisha government.



Awaiting analysis

There is considerable area-specific CKD knowledge that local doctors and health officials have of their regions. Strangely, however, while they quote examples of similar patterns that have emerged internationally — Sri Lanka, the Balkans — most doctors in each of these regions have no idea that a similar condition is being recorded within the country itself.

Among the few who have information on all the four regions is nephrologist Dr. Vivekanand Jha who, as former secretary of the Indian Society of Nephrology, had heard about the incidence from doctors from all four areas. He had led the ICMR team to Uddanam in 2012 to survey the CKD prevalence, and on his return proposed a study, ‘Chronic Kidney Disease of Unknown Etiology’, to the ICMR. Four years on, the study awaits funding. In response to a query from The Hindu, the ICMR said that owing to funding constraints at the institute, it has requested the Directorate General of Health Services and the Health Ministry to assess CKD in the four areas.



“Whatever has been done (surveys) lacks scientific rigour. The observations may or may not be true. While there is no doubt this is a water issue, the explanation is then not limited to one area,” says Dr. Jha, who researches kidney diseases and is professor of nephrology at Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh.

He points out that this isn’t just a health issue, but a human rights issue as clean drinking water is a fundamental right: “It is developing disease by neglect.”



roli.srivastava@thehindu.co.in

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Printable version | Apr 10, 2020 12:42:31 PM | https://www.thehindu.com/opinion/op-ed/Quadrants-of-a-renal-quandary/article14176454.ece

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