Environmental Pollution & Chronic Kidney Disease of

“Multi Factorial Origin” in Sri Lanka

Sunil J. Wimalawansa, MD, PhD, MBA, DSc Professor of Medicine

New Jersey, USA

Environmental Pollution & Chronic Kidney Disease in Sri Lanka: Key sponsor:

Engineers Without Boarders/Sri Lanka

EWB-SL is volunteering to come up with solutions to the CKD problem

Outline • Water, sanitation, pollution and diseases • Definition of Chronic Kidney Disease (CKD)-

of multi factorial origin (CKD-mfo) • What causes CKD-mfo • Engineering solutions for CKD: Clean water • Reverse osmosis method to overcome CKD • Sustainable solutions to overcome the

problem

90% of these deaths occur in economically

poor countries

Why this disparity?

In Every 15 Seconds, a Child Dies from Water-Related

Disease (U.N.)

How Does Water Get Polluted?

• Domestic: disposals, chemicals... • Industries: agriculture, manufacturing.. • Production: gasoline, chemicals, etc..

Natural Disasters are Destructive and Lead to Water Pollution

Post-Tsunami environmental and water pollution

Floods Lead to Water Contamination

Flood Causes Water pollution

Main Causes of Water Polution “Microbial” contaminants ― bacteria and viruses:

– Contamination via sewage and septic systems

– Agriculture, livestock operations, and wildlife

“Inorganic” contaminants ― salts and metals: – Can be naturally occurring, or – Agrochemicals; storm water runoff

– Industrial or domestic wastewater – Oil and gas production, mining, and farming

Preventable Water Pollution

Poor Sanitation and Water Pollution

Toxins & Chemicals Affect The Whole Body

• Brain • Cardiovascular system • Intestine • Skin and eye/sensory system • Immune system • Liver and Kidneys

Consequences of Drinking Contaminated Water

• Acute illnesses –Water-borne diseases –Diarrheal diseases –Dehydration and death

• Chronic illnesses –Fluorosis –Chronic liver diseases –Chronic kidney disease

• High morbidity and mortality

Chronic Kidney Disease

Anatomy & the Functions of The Kidney

Preferred Terminology for CKD • CKD of Multi-Factorial Origin (CKD-mfo) (the term, I have been using since 2007) • CKD-mfo is an “Environmental” Disease

that cause by - several factors • When the “conditions” are unfavorable

to kidneys, it begin to fail • It causes tubulo-interstitial sclerosis;

Thus, it is irreversible • Prevention is the only cure

Rajarata Kidney Disease: Causes? • No one is certain what is going on • Too much speculations: Inadequate research

data to make meaningful conclusions • Multiple interactions escalate toxic effects • Unregulated / illicit medicine and alcohol • Role of NSAID, leptospirosis, smoking, and

others―totally neglected • Unforeseen, unpredicted, or neglected reasons • Combination of various unhealthful issues

Prevalence of Chronic Kidney Diseases in NCR

• In certain villages in NCP, the prevalence of CKD is between 8 – 10 %, of the population

• Region-wide, the average prevalence is ~ 5%

Geographical Distribution of CKD

in Sri Lanka

CKD-mfo: Endemic Areas

Predominantly Affected Districts:

• Anuradhapura • Polonnaruwa • Badulla • Hambantota

Distribution of CKD in SL

Also now in: Southern Wellawaya, Thanamalvila, Lunugamvehera, Tissamaharama, etc.

Occupational Distribution of CKD Pts.

Category Number % Farmers (male) 174 56 [71%] House wife 29 9.4 Labors 15 4.9 Businessmen 05 1.6 Carpenters 05 1.6 Postman 03 1.0 Gramasewaka 02 0.6 Others 13 3.9 Missing data's 63 20

Age Distribution AGE / YEARS NO %

0-10 00 00.0 11-20 04 01.3 21-30 29 09.4 31-40 57 17.4 41-50 73 23.6 51-60 73 23.6 61-70 51 16.5 71-80 10 03.2

Missing data's 12 03.9 Total 309 100.0

63%

Multiple Aetiologies Leads to Development of Chronic Renal Failure

Potential Culprits: Lack of adequate hydration (chronic

dehydration) – GI absorption issue Heavy Metals: Cadmium /Arsenic /Lead Fluoride / aluminium / hard water Pesticides / herbicides / Nitrates NSAID / leptospirosis /illicit alcohol & drugs Unidentified toxins

NSAID / leptospirosis /illicit alcohol & drugs Unidentified toxins

Rajarata CKD Epidemic

• Pathological feature of CKD-mfo is “interstitial nephritis”

• The aetiology of it is unclear • CKD-mfo is not an immune, congenital,

genetic, or an infectious disease • It is a disease that is acquired by

“environmental” exposure • Real time bio-surveillance is necessary

Potential Water Pollutants in NCP that Cause CKD

Heavy Metals

Agro-Chemicals

Fluoride Heavy Metals

Heavy Metal Toxicity

Cadmium

Arsenic

Lead Mercury

Evidence on Toxins from Algae as a Cause

of CKD?

War-related pollution and

bio-terrorism in previously

endangered villages are not

causes of Rajarata kidney

disease

Water Hardness is Unlikely a Major Source for CKD

• Hardness of water is mostly caused due to presence of cations, Ca2+ and Mg2+ , prevailing across the island for hundreds of years.

• It may be associated the presence of Fluoride, Cadmium or Asenic.

• The natural ground water hardness does NOT correlates with CKD distribution

Distribution of Ground Water

Hardness

Distribution of CKD Patients

Role of Pesticides and Others Agrochemicals Causing CKD

Paddy Fields Are A key Source of Water Contamination in NCP

Artificial fertilizers Pesticides, weedicides

& Fungicides

Excessive uses of

Annual Chemical Fertilizer Consumption in South Asian Region 2012

Country Fertilizer consumption (Kg/hectare of arable land)

Sri Lanka 284.3 Bangladesh 164.5 Pakistan 163.3 India 153.5 Bhutan 9.0 Nepal 7.7 Source :http://data.worldbank.org/indicator/AG.CON.FERT.ZS

Can We Control Pests Without Toxins? We Can Control Pests Without Toxins

Ways of Purifying Water

Ways of Purifying Water Need to develop an affordable

methodology to purify water applicable to:

• Domestic use: for less fortunate communities

• Community-based small local plants

• Filtration vs. chemical purification

• Predictable, easy to operate & maintain

• Household vs. larger scale purification

What Works in the Field?

• The use of charcoal, sand, and brick (individually or in combination) do not meaningfully remove heavy metal or fluoride.

• Anything given free, people will consider worthless; hence some nominal amount should be charged to make them feel responsible and taking the ownership.

We Have Tasted Several Commercial Water Purification Filters for Efficiency in the Lab

Efficacy of the Locally available Filters in Removing Heavy

Metals, Fluoride, Agro-chemicals, and Bacteria

None of the filter material tested in the laboratory was efficient in removing potentially serious water contaminants in NCP region. We need a New Method.

Real World Water Solutions (in order of long-term cost-effectiveness)

• Natural spring water • Rainwater harvesting • Wells, and deed tube wells • Provision of pipe-borne water • Water transportation • Boiled, cooled water

• Desalination • Bottled water (the most expensive) Reverse osmosis: The most applicable

What is Happening Now

• Every month, over 400 people are dying of CKD-mfo in 2013

• i.e., 13 deaths per day! • Should we continue neglecting

those who are affected, suffering and dying form the CKD?

Do We Really Need to Confirm Causative Factors Before Taking an Action?

• Over 10 years of CKD-related investigations, failed to come to a conclusion of the cause of CKD.

• No substantial actions have been taken.

• Yet people are dying every day.

We Need Long-Term Solutions • Intense public awareness • Effective water purification methods • Prevention of water contamination

– (agriculture, waste, and sewage disposal) • Use of environmentally friendly

agricultural practices • Reverse osmosis methodology • Provision of centrally purified pipe-

borne water supply to every one

Cost-efficiency of R/O Units • Deaths due to CKD in the affected region

approximates 5,000 per year (13 a day)!

• Thus, each $650 spent on this project will prevent one CKD death per year.

• Over the expected life span of 30 years of an R/O pant, investment of US $23 prevent one death

Cost of one restaurant meal !

Educational Posters

Educational Posters

We Must Provide Clean Water for All

Dialysis Units are not the Answer to Solve this Issue

Setting up Large-Scale Dialysis Units is NOT the Answer to This

Ongoing Problem: We Must Take Preventative

Actions: Actions Needed to Prevent

Healthy People Acquiring CKD

Prevention of CKD in The NCP Region

Functions and Failure of the Kidney

• Recognition of the impact of different environmental conditions

• (In)appropiate continued spending on authorities like Mahaweli (and others)?

• Re-allocation of resources to: – Restoration of cascade of ancient tank

system, and – Village-level activities to re-vitalize the

rural societies

Focus Should Be on Prevention and Sensible Reallocation of Resources

Solution to CKD Problem Must Include

Science & Research

Medical

Engineering Environmental

Provision of Reverse Osmosis Would • Prevent new occurrence of CKD in healthy

farmers

• Also decrease other chronic diseases that prevalent in the region

• Clean water consumption should reverse the trend of sicknesses, and thus, enhance productive lives

• Installation of Reverse Osmosis plants are the best way to achieve these goals

Focus Should Be on Preservation, Improve Access, and Prevention of

Water Pollution • Preservation of waterways, canals,

underground water, and tanks

• Regulation and maintenance of the quality of the water in tanks, wells and tube-wells

• Prevention of water pollution and alleviation of its adverse effects

Key Missing Pieces

• Use of proper sampling techniques • Use of well-characterized

instrumentation for water analysis • Hazard identification • Risk assessment • Dose/response data • Risk characterization • Management and communication

Practical Steps to Be Taken

• Explore alternative water conservation methods

• Empowerment of women & youth • Rainwater harvesting • Attention to sanitation

• Provision of sustainable drinking water and toilets in public places, schools, and workplaces

Current Priorities: Commitments and Raising Funds • Regional and country-wide awareness

programs on prevention of water and environment pollution.

• Provision of clean, safe drinking water to all CKD-affected villages in Sri Lanka.

• Region-wide, geo-water-health study. • Obtaining funds, and corporation from

all stake-holders to rapidly implement this worthwhile project.

What We Need to Do ? • SLGo to categorically authorize the CCPO, The

Consortium to carry our region wide: – Education on prevention of water and the

environmental contamination – Provision of clean water to all villages – Carryout region-wide geo-water study

– Allocate funds for the project

• In parallel, individuals, organizations, and corporations should raise funds for the project

• CCPO is READY to implement the project

Overcoming The CKD Issue in NCP

• Never doubt what a committed group of people can do for the country

• When resources and expertise are inadequate, evolve & adapt to the situation

• Need to provide an economic viability to the region

• Change the fundamental • Need honest leadership and investments to

overcome poverty and diseases

Thank you………

Questions and

discussion

Suniljw@hotmail.com

www.wimalawansa.org