Sri Lanka’s next big fight

Unlike in its successful battle against malaria, the country has a peculiar challenge as it tries combating this disease — establishing a cause

January 08, 2017 12:07 am | Updated 02:55 pm IST

The International Society of Nephrologists (ISN) recently honoured Sri Lankan President Maithripala Sirisena for his “extraordinary contribution” to the fight against Chronic Kidney Disease of Unknown Etiology (CKDu).

The recognition comes months after the World Health Organisation declared Sri Lanka “malaria-free”, a significant public health achievement in the region.

Unlike in its fight against malaria, Sri Lanka has a peculiar challenge even as it tries combating CKDu — an unknown enemy. The medical fraternity has been grappling with the question for years now and is yet to establish a cause that has scientific evidence backing it, according to President of the Sri Lanka Association of Nephrologists, Chula Herath.

‘Silent condition’

While hypertension and diabetes are known to be common causes for kidney ailments, CKDu falls outside that ambit. “In every renal data base in the world there is a percentage of CKDu which causes long-term progressive damage to the kidneys,” he told The Hindu at Sri Lanka’s Sri Jayewardenepura General Hospital. However, he clarifies that not all undiagnosed cases are CKDu, a specific term used to connote conditions where causal factors remain unknown. Describing it a largely “silent condition”, he says symptoms are seldom manifested till the final stages. “It is like this — when you drive a car, you won’t feel the petrol running out until the vehicle stops, unless you check periodically.”

CKDu was in the news some years ago when farmers working in Central America’s sugar cane farms succumbed to a “mysterious” kidney disease. In both Central America and Sri Lanka, reports of the condition first began emerging sometime in the 1990s, according to Dr. Herath. In 2014, Sri Lanka media widely reported on a “mysterious” kidney disease spreading among farmers. “More recently, there are reports of the disease in some parts of Andhra Pradesh, among people from the agricultural community.”

In Sri Lanka too, it is the agriculture-intensive North Central Province where the condition is highly prevalent.

Speaking at the award ceremony in Colombo in December, Mr. Sirisena said CKDu was endemic among poor farmers in Sri Lanka. He pointed to 20,828 patients and 5,000 deaths per year, terming it a “national disaster”.

Mr. Sirisena, who served as Health Minister in former President Mahinda Rajpaksa’s cabinet, is from Polonnaruwa in the North Central Province, where agriculture is one of the key drivers of the economy. Given CKDu’s prevalence in his constituency, and his own familiarity with public health, he set up a presidential task force to address the problem.

Additionally, he prompted Colombo-based entrepreneur and proprietor of the sea-side Galle Face Hotel Sanjeev Gardner to set up a fund to support initiatives aimed at curbing CKDu. The ISN-Gardiner Fund (ISN-GF) launched on the occasion would aim to fight CKDu not just in Sri Lanka but in the region and at the global level. Experts from the region, including senior Indian nephrologist Georgi Abraham, have been roped in to play a key role in the initiative.

The focus, so far, has been largely on curative measures, Dr. Herath says, explaining that effective preventive measures could not be evolved without knowing what causes the condition. Dialysis and transplantation are the common medical responses, depending on a patient’s condition, but the country’s available medical infrastructure is overstrained with the increasing incidence of CKDu, he notes. Sri Lanka, after consistent efforts to strengthen its CKDu response mechanisms currently has nearly 400 dialysis machines. The country needs at least 1,000 in the coming year, by nephrologists’ estimation. About 350 live kidney transplants and 20 cadaveric kidney transplants are performed in Sri Lanka every year and “both could increase,” Dr. Herath notes.

Preventive measures

Working on prevention is not easy because nephrologists across the world have only assumptions to go by. “There is a lot of hypothesis that agrochemicals and contaminated water could be likely causes. While we do not have evidence to prove this, the public health system is trying to intervene through some preventive measures,” he says. Local government officials involved in the campaign now focus on providing good quality drinking water, raising awareness about the risk of dehydration and ensuring supervised use of agrochemicals and fertilisers.

Science writer Nalaka Gunawardene, who has been commenting on CKDu, observes that while the government’s current efforts in responding to what has become a “slow national tragedy” merits recognition, it should not take hasty decisions on regulating the use of agrochemicals. “There are more than 30 hypotheses on the causes of CKDu, but the environment lobby has cherry-picked one or two possible causes,” he says. Emphasising that the regulation of agrochemicals be done on its own terms, he says it was crucially linked to the country’s food security and farmers’ income security. “We should slowly wean agriculture from agrochemicals,” he says, adding that meanwhile Sri Lanka needed to expand its resources, and build on available expertise.

Given all the challenges, Sri Lanka has come a long way in responding to CKDu, doctors say. In the mid-1990s when the cases first emerged, the government hospital in Anuradhapura, in the North Central Province, did not have a renal care unit, recalls Asanga Ranasinghe, National Coordinator for Kidney Disease Prevention and Research, Ministry of Health. “But now there is a 9-storey building with a special renal unit,” the senior public health official says.

“The concrete etiology [medical cause] is yet to be found, but if we wait until scientific symptoms manifest, a patient might have already lost up to 60 per cent of his kidney function by then,” Dr. Ranasinghe says, pointing to the government’s current thrust on early detection. There is no cure but timely diagnosis and dialysis could help prolong kidney function.

Apart from facilities for regular screening, the Sri Lankan government embarked on an initiative to provide purified water to endemic areas. “We have covered almost 97 per cent now,” he says.

The Health Ministry has begun sensitising its officials in every district to the condition. “We are also training our public health workers at the grass-roots level. Our public health infrastructure is gearing up in a big way,” Dr. Ranasinghe says.



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