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I have read 8-10 articles in national newspapers as well as in several other sources during the last couple of weeks, emphasizing the importance of providing safe and clean drinking water to the people in CKD (Chronic Kidney Disease) affected areas where the illness has been caused by non-traditional causes.

After reading them, I felt that some, especially those who are writing from abroad, are unaware of what is happening in the ground, with respect to the CKD issue.

In 2008, we pointed out the importance of providing safe drinking water to the CKD endemic areas in the dry zone. However, the majority of policy makers and so call leading scientific community were reluctant to accept it claiming that this is a disease of unknown etiology and no interventional program should be started until the etiology is confirmed. Even after seven years, these armchair scientists continue to name the disease as CKDu where “u” denotes unknown or uncertain etiology (some prefer to use the upper case “U” instead of using the lower case “u” which is the official form introduced by the Ministry of Health Sri Lanka in a circular issued in 2009). These scientists only provide hypothesis (upanayasa) and mere imaginations (hithalu) but no data. However, with the existing findings, we are in a position to rename the disease as Sri Lankan Agricultural Nephropathy or Chronic Agrochemical Nephropathy. On a wider basis, we prefer the term Tropical Agrochemical Nephropathy. CKD due to non-traditional causes is another acceptable term (CKDnT). Ironically, the same people who were against the provision of safe and clean drinking water earlier, claiming the non-existence of scientific evidence to link CKDnT and drinking water, are now writing to newspapers and are clamoring for it as the solution to the problem. On the other hand, they are of the view that the etiology of CKDnT among farming communities is still unknown and water is not polluted with any nephrotoxic substances. Further, they reiterate, toxins originating from agrochemicals (pesticides and chemical fertilizers) are not even a risk factor for the disease. Then what is the rationale for providing safe drinking water to eradicate the disease, when the drinking water is not linked to its etiology? Even the WHO study does not pinpoint any kind of kidney toxins in the drinking water. However, WHO report confirmed our finding that CKDnT in rural Sri Lanka is linked to consuming hard water from shallow wells that may contain other contaminants due to agricultural washout.

The same, so called scientists are propagating the story that we have just fought for banning glyphosate. Banning glyphosate was just a one facet of our struggle. There is a scientific discipline devoted to study the distribution and determinants of health related states or events in specified populations, and the application of this study to the control of health problems. It is called Epidemiology. With epidemiological investigations we provided evidence that continued use of pesticides for rice cultivation, contamination of drinking water supplies with metals and pesticides are the most important risk factors for rapidly spreading CKDnT. It is a well-known principle in Occupational and Environmental Medicine to eliminate or minimize the exposure to suspected toxins until they are proven to be safe. Our main attention was paid to providing hardness free, heavy metal free, and pesticide residue free drinking water to the people in CKDnT endemic region.

Ultimately policy makers and politicians started providing clean water to people. This was a powerful blow to the opinion generated by bureaucratic scientists who really insisted on finding out the etiology first while watching thousands die without intervening with available evidence and safeguarding their hegemony in Sri Lankan academic arena. Currently there is an argument among many about the best solution to CKDnT with a debate around how to provide clean water. With a lot of difficulty, we were able to convince the majority about the link between the contamination of drinking water with agrochemicals and chronic agrochemical nephropathy/CKDnT and the ill effects of agrochemicals.

Why do we have to provide hardness free, heavy metal-free, pesticide residue free water to the people in CKDnT endemic areas of Sri Lanka? First, the kidney toxic herbicides (glyphosate and previously paraquat), arsenic, heavy metals and hard water act together within kidney tissues and gradually destroy normal renal function. Second, there is chronic and repeated dehydration, which is a contributory factor for further kidney damage.

Another idea claims Mahaweli water could be the culprit for CKDnT. Diversion of the Mahavali River may have contributed to the disease by altering the quality and quantity of the ground water table in Rajarata. But it’s highly unlikely and irrational to say contaminants in the water supplied by Mahawali scheme is the cause for the disease.

Majority of CKDnT patients in Rajarata never consumed water from Mahaweli and the majority of people who consume Mahaweli water do not exhibit the disease. This misunderstanding may arisen because many CKDnT endemic regions are originally named as Mahaweli areas but do not receive Mahaweli water. These false assumptions occur when people (living abroad) are trying daydreaming without knowing the ground situation.
What is the best way of providing clean drinking water to Rajarata? We have discussed this issue at length and arrived at the following conclusions in 2011 based on the principle that, right to water is a basic human need and providing clean drinking water to all humans is mandatory. This view is diametrically opposed to market environmentalism.

1.Renovate 250-300 small and medium scale ancient reservoirs ‘wewa’ to provide drinking water.

2.Service extensions from existing pipe-borne water supplies that obtain water from surface collections.

3.Distribution of spring-water

4.Introduction of small and medium scale Reverse Osmosis (RO) plants as a temporary measure.

5. Providing good quality pipe-borne drinking water

6.We are of the view that Reverse Osmosis is not a permanent solution. However, we had to recommend RO plants as a short-term measure until the water board develops its capacity to provide safe drinking water on a large scale.

There is also a discussion about rainwater harvesting. However, most people are not in a position to accept it as a solution. Several NGOs have donated rainwater-harvesting tanks to the Rajarata even prior to the emergence of the agrochemical related nephropathy. However the ground reality is that people are reluctant to use this water for drinking.
We are not web-watchers or newspaper columnists, but have been working hard to implement our solutions to protect the environment and prevent the accumulation of these contaminants in Rajarata soil. We convinced the previous government to repair 50 small wewas and implemented it for drinking purposes. Personally, I made a request to then Secretary to the Ministry of Finance and he allocated money to install medium-scale RO machines in 85 schools in the North Central Province (NCP) and in 40 schools in Uva province. This project was implemented through Ministry of Water Supply and Water Drainage. Shanthi foundation, Australia donated 16 RO machines to the schools. Shraddha television channel donated 10 large-scale RO machines to severely affected villages. At least another 25 medium scale RO machines have been donated by several Buddhist organizations, politicians, leading business firms and welfare societies with our intervention and collaboration.

There was an era when nobody talked about CKDnT. People who did not talk or write a single word about these innocent people who were suffering silently from the dire consequences of this deadly kidney disease seem to suddenly want to become heroes in the national media.
The author is form

The Faculty of Medicine
Rajarata University of Sri Lanka
Anuradhapura