Chronic kidney disease in Rajarata, worse than tsunami
Safe drinking water is a fundamental human right, but more than 2.0
billion people in the world still lack access to safe-clean drinking
water and to sanitation; Sri Lanka is no exception. Contaminated water
and poor sanitation claim more lives than any war or any single disease.
Toxic chemicals or organisms affecting health cannot necessarily be
seen, tested, or smelled. Provision of clean water and sanitary
facilities can save over 3 million lives globally and about 10,000 in
Sri Lanka, annually.
Geographical and other issues
A casualty with his head on mother's lap
Chronic Kidney disease (CKD) primarily affects middle-aged farmers.
The CKD of multi factorial origin (CKD-mfo) in Sri Lanka is
geographically demarcated, but is spreading to adjoining areas around
the North Central Province (NCP) and elsewhere in the country. The
farming communities are predominantly affected; of which more than 90%
live in rural areas with little access to medical or preventative health
facilities. Currently, the CKD-mfo-prone areas cover approximately
20,000 km2, and potentially affecting about 2.8 million Sri Lankans.
The occurrence of CKD is likely dye to consumption of polluted
water/food, or yet unknown and thus, uninvestigated cause. Adverse
environmental conditions, recent environmental unfriendly irrigation and
agricultural methods, excessive use of phosphate-rich (and perhaps
contaminated) artificial chemical fertilizer and toxic agro-chemical,
and mishandling of petrochemicals, all may play a role in causing
CKD-mfo; but no causality is demonstrated. It is paramount to launch an
island-wide campaign to reduce the usage of artificial chemical
fertilizers and toxic agro-chemicals, which necessitates gradual
reduction of agro subsidies. All available data suggests that the
CKD-mfo is an "environmentally" acquired disease.
Causes and incidence of CKDu
The water and food in the certain affected areas is polluted with low
levels of toxic heavy metals, cadmium, arsenic, and lead, as well as
with flouride, and toxic agro-chemicals and petrochemicals. Although the
specific cause for the CKDu is unknow, it is of multi-factorial origin,
and is due to a combination of chemicals and toxins that are prevent in
this area. However, CKD-mfo can precipitate in the presence of other
pollutants and toxic components that have not yet been investigated. The
exact incidence or the causes of CKD are unknown, but over 100,000
people are currently affected (up to 10 to 15% of people in certain
villages); unfortunately, the incidence continues to increase.
Therefore, an urgent, cost-effective solution is necessary.
Approximately 400% of the inhabitants in Sri Lanka have access to
clean, pipe-borne water supply. It is the prime duty of the Water Supply
and Drainage Board to provide clean water via the same system to the
remaining 60% of the population. People live in
villages should have the same privileges of having clean potable
water provided via centrally purified pipe-borne water supply, that
enjoy by the city dwellers. However, this may take another three decades
or more to materialize fully. Unless intervene now efficiently, by then
an estimated 250,000 predominantly middle-aged farmers will be
succumbing to CKD-mfo.
There are no curative measures for those who acquire CKD-mfo, thus,
prevention is the only way forward. Other than providing centrally
purified pipe-borne water or clean water via reverse osmosis method,
there is no other sustainable way of providing clean water to the
affected villages, most of which are located in remote areas.
However, this must be implemented systematically and based on
scientific basis. None of the variety of commercial filters that has
been introduced to the area seems capable of removing the potential
chemicals and toxins efficiently.
The North Central region desperately needs a cost-effective way to
provide safe and clean water for its farming populace. Our analysis
indicates that the Reverse Osmosis method is the most cost-effective,
sustainable and environmentally friendly system than can remove all
toxic components from the brackish water in NCP. However, not all
reverse osmosis units are the same. Thus, it is imperative to install
the right reverse osmosis water purification unit in a given village to
provide clean water. Depending on the water quality/turbidity,
electrical conductivity, chemical constituents, turbidity, etc., a
pre-filter is necessary for the RO units. Philanthropic organizations
and the water board are currently installing pilot units in villages in
the Anuradhapura district. However, the Rajarata area requires
approximately 400 of these reverse osmosis unites to provide clean water
to its inhabitants.
Education, awareness and pollution prevention campaign
It is utmost important to initiate a region-wide awareness campaign
on prevention of environmental pollution. This educational program must
include (A) consequences of drinking contaminated water, (B) the
importance of using safe and clean treated water, (C) water
conservations methods, prevention of pollution of water sources and the
environment, (D)essential precautions to be taken by farmers when using
agrochemicals, (E) utilization of locally available organic substances
and compost for cultivation and for pest control, etc. We have an
on-going village level educational cum informative campaign on this
since 2008; however, this needs to be intensified.
Provision of clean water to Rajarata
1. Prioritisation of villages to provide reverse osmosis water
2. Identification of the right RO units for the right village: as
cost-effective, practical and sustainable way to provide clean water -
via water treatment technology (removing all potential pollutants).
3. Availability of sustainable sources of brackish-water and method
for clean water distribution.
4. Set-up infrastructure for proper operation and long-term
maintenance of reverse osmosis plants.
5. Awareness program to encourage people to use clean water for
drinking and cooking.
6. Regular monitoring of water quality as an integral part of the
operation and maintenance.
7. Long-term data collation and systematic assessments to eliminate
health problems in the region.
8. Capital, operational, maintenance and distribution costs; and cost
Cost of installation reverse osmosis plants
On average, reverse osmosis plants costs about Us $8,900 to install
(cost varies from $4,000 to $25,000, each unit). An average reverse
osmosis unit provides safe and clean water to approximately 1,500 people
(one or a cluster of 2 to 4 villages). We estimate that the entire
region requires approximately 400 reverse osmosis plants, at a cost of
US $4 million (500 million Sri Lankan rupees).
The number of deaths secondary to CKD in the affected region
currently approximates 5,000 year. In spite of the diagnostic
underestimations, this amounts to deaths of 13 farmers a day. Thus, each
$650 spent on this project will prevent one CKD death per year.
Therefore, over the expected life span of 30 years of an RO pant,
investment of US $24 will prevent one death in Rajarata. Therefore, the
proposed region-wide intervention is highly cost-effective.
With an estimated rate of 1% CKD-mfo related deaths, each reverse
osmosis plant prevents approximately 10 deaths in a village, per year.
Thus, over a 30-year period, each reverse osmosis plant will save about
300 lives. There is no medical or any other intervention where one could
offer a solution to this region that is more cost-effective in reducing
diseases burden and premature deaths.
Expectation and the hypothesis
The provision and the consumption of clean water will prevent the new
occurrence of CKD-mfo. It would also decrease other chronic diseases and
diarrhoeal diseases prevalent in the region. In 2012, department of
health spent 3.6% of its annual budget, 350 million rupees to treat
patients with CKD-mfo, and this cost is escalating. We estimate that the
implementation of this proposed broader project would save about 500
million rupees per year in the health department budget alone. In
addition, improvements in health reflect with increase productivity.
Especially paddy and other agricultural productions in the region.
Therefore, a rapid capital cost recovery is expected after commencing
Commitments and raising funds
A) Regional island-wide educational campaign on prevention of water
and environment pollution.
B) Provision of clean, safe portable water using RO systems to
CKD-affected villages in Sri Lanka.
C) Broad-based, environmental and sociological research program for
CKD-mfo affected areas.
D) Government to provide adequate funds, and to develop
collaborations and private-public partnerships, particularly with the
not for profit sectors to implement the project and its longer-term
maintenance in the region.
Once funds allocated, the Consortium of Concerned Philanthropic
Organisation will (A) launch a extensive awareness campaign on
prevention of environmental pollution and encouraging farmers to use
less agro-chemicals, (B) professionally install reverse osmosis plants
in the entire region providing clean water to all affected villages
within the next 18 months, and (C) carry out a truly multi-disciplinary,
prospective, long-term geo-water, health and socio-economic research
program that covers the entire region. In addition to providing clean
water, proposed project will also embrace on the provision of sanitary
and toilet facilities. We look forward to undertaking a firm commitment
by the government, provides adequate funds for the Consortium to
implement this sustainable and extensive plan.