CKD Flyer PHEPRO.org Sri Lanka

8/12/2019 CKD Flyer PHEPRO.org Sri Lanka

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Escalating Chronic Kidney Disease in North Central Province:A Plan of Action to Eradicate it From Sri Lanka

The following document is a proposed plan of action by the *Foundation, aimed at controllingwidespread water and soil pollution in the North Central Province (NCP) of Sri Lanka and the resultingepidemic of Chronic Kidney Disease (CKD), which is responsible for killing thousands of people everyyear. The number of deaths and costs for managing this disease are markedly escalating. It details sixprojects (projects 1, 2, 3 & 6 are prioritized) the Foundation sees as crucial steps to reversing CKD epidemic.

Proposed objectives(details in page 4; to navigate flyer, please use the index on the right side):

Sub-Project 1:Educating health professionals

Sub-Project 2:Provide and educate, effective use of water quality measurement devices

Sub-Project 3:Educational campaignprinting of posters to increase awareness

Sub-Project 4: Poverty alleviation, job creation, disease prevention and improve nutrition

Sub-Project 5: Develop and fund a network of relevant CKD-mforesearch for local scientists

Sub-Project 6:Purchase, install, and maintain reverse osmosis water purification plants

Sub-Projec 1:Educain heah proessionas

Sub-Projec 2:Proide and educae, eecie use o waer uai easureen deices

Sub-Projec 3:Educaiona capainprinin o posers o increase awareness

Sub-Projec 4:Poer aeiaion, job creaion, disease preenion and iproe nuriion

Sub-Projec 5:Deeop and und a nework o reean CKD-o research or oca scieniss

Sub-Projec 6:Purchase, insa, and ainain reerse ososis waer puricaion pans


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PHEPRO Foundation:A Unified Organization to Overcome theChronic Kidney Diseases of Multi Factorial Origin in Sri Lanka*The Preventive Health, Environmental Protection, and Research Organization (PHEPRO.org)consists of charitable organizations interested in eradicating CKD-mfo in Sri Lanka. Until thePHEPRO.org is fully functional, WETF and HBP will manage accounts and the projects. Thesetwo organizations will take the leadership with the Dhamavijaya Foundation (DVF) and others,implementing this important humanitarian program. In addition to quarterly account reports byCPA, accounts will be audited in USA and in Sri Lanka by reputed audit-firms.

Your financial support is critical in helping us to carry out the six projects described in page 4: toprovide education, clean water and relief to thousands who either have or are at risk of contracting

this deadly disease, CKD of multi-factorial origin, particularly affecting the North Central Province.

Information for potential donors for donating funds to this worthwhile cause

HBP Foundation, North America (worldwide): WETF-Foundation (Donations in Sri Lanka):

Charitable registration #: EIN: 27-1836636See the button below for donation viaPayPal

US Bank, St. Cloud Downtown Office1015 St. Germain St, St Cloud, MN 56301, U.S.A.Checking A/C #: 1-047-5774-9338

Routing number: 091000022USBK US44IMT [HBP is a registered charity in USA]

Checks may be payable to HBP, CKD-Projectand mailed to:

Professor Susantha Herath2716, Edward Drive, St. Cloud, MN 56301

Tel: U.S.A.-1- 320-308-2189

Email: [email protected]

Charitable status pendingPayPal donation to Sri Lanka is not available

Bank of Ceylon, Lake View Branch, No 142Sir James Peries Mawatha, Colombo 02,Sri Lanka

Bank A/C #0000306141Swift Address BCEYLKLX

Tel: 0094-112314207; Fax: 0094-112303143

Checks may be payable to WETF,CKD Project,and mailed to: Mr. Athula JayalalNo.105, Hunupitiya Lake Road, Colombo 02

Tel: 0094-115-700-400; Fax: 0094-112-472-535

Email: [email protected]

Please Donate to Support the Mission!The two foundations accepting donations to the CKD project

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HBP is a Reisered Chari in USA
https://www.paypal.com/cgi-bin/webscr?cmd=_s-xclick&hosted_button_id=RKG9BHWHNZPJ2


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A Plan to Action to Overcome Chronic Kidney Disease in Sri Lanka

Introduction:

Approximately 5,000 farmers in North Central Province (NCP) in Sri Lanka aredying each year of Kidney failure mainly due to CKD, but many are undiagnosed.

Major effort is needed to reduce these deaths by education, training, andmonitoring water quality and supply of purified clean water to them.

Most of those affected regions in the country are in agriculturalareas, in which more than 90% of the population lives in ruralcommunities with little access to amenities such as safepotable water, good sanitation and modern medical facilities.A major intervention is needed immediately to preventpremature deaths and to stop the spread of this disease.

Each day, approximately 13 middle-aged male farmers aredying from Chronic Kidney Diseases (CKD) In the NCP.Consequently, in some families there are no surviving

adult men. Much is needed to be done urgently especiallyin prevention; a daunting task for the authorities.

The incidences of deaths caused by this Chronic KidneyDisease of multi-factorial origin (CKD-mfo), previously knownas CKDu, CKDuo, and CKDue is likely to increase with time.The exact causes of CKD-mfo are unknown, but more than100,000 people are currently affected (between 10% and 15%of people in certain villages), with an approximate 5% annualdeath rate among the affected. In addition, it is estimated thatapproximately 2.8 million people are at the risk of contractingthis deadly disease, and based on the current estimates basedon the incidence, about one-million will be affected with time.Figure 1 provides information on the most-affected areas andthe trend of its spread both within and outside the NCP.

Consequence of not having clean water to Rajarata/NCP:

Projection suggest that unless intervened now and if theCKD related premature deaths of adult males continue atthe current rate, only 10% of the adult male populationwill survive in the NCP by the year 2045 compared with2013. This will be disastrous not only for those families, but italso would markedly change the demographics, andadversely affect the countrys rice sufficiency and theeconomy. Moreover, current statistics show that the

deaths from the CKD-mfo have already outnumbered thehuman losses attributed to the 2004Tsunami.1 Delays in

urgent and effective preventive strategic solutions to reduceKidney failure due to water pollution would cause irreparable

losses to our nation.2 The affected area was popularly known to travelers of the past as the

GRANARY OF THE PEARL OF INDIAN OCEAN!

1 http://www.dailynews.lk/features/knocking-kidney-killer; http://www.sundayobserver.lk/2013/11/24/fea06.asp

2 http://www.island.lk/index.php?page_cat=article-details&page=article-details&code_title=98247

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Proposed Plan of Action[line item costs are provided in the page 5]:

The provision of clean water [Project 4] although essential, byitself is not sufficient to eradicate CKD-mfofrom the country. It is critical to provide the right information to healthcare professionals regarding ways toeradicate the disease [Project 1];for the public, efficient and cost-effective way of identifying/ quantifying,the polluted water sources [Project 2]; and educating environmental pollution prevention [Project 3].Preventive Health, Environmental Protection, and Research Organization (PHEPRO.org)will conduct six

projects with other organizations to help overcome the chronic kidney disease (CKD-mfo) in Sri Lanka.Project IEducating Health Professionals [Budget for printing 34,000 copies = US $33,282]:

Educating and empower health professional and to bring them on the same page is an essential part of thisproject; without which the project is unlikely to be successful. White Paper on CKD is a comprehensivebook on CKD-mfo, which include everything one needs to fight and eradicate this diseasesteps that needto taken by the community and Government. Copies of this will be distributed to all physicians and hospitaladministrators [Step 1], to facilitate professionals to fight the disease on a unified platform with unifiedmessage. This book will be translated to Sinhela and Tamil, and give to all auxiliary healthcare workers.We will also involve active participation of the news media for wider education of the public and todisseminate right messages on prevention of pollution, taking care of themselves and minimizing theincidence of non-communicable diseases.

Step 1:We will print and distribute 8,000 copies of the book to all medical officers through the Government

Medical Officers Association of Sri Lanka (GMOA); the distribution and associated cost will be borne bythis Association [Total cost of printing and distributing 8,000 copies in English = [$12,062].

Step 2:Additional 5,000 copies of the book will be printed and distribute among others in the healthcarefield such as Health Administrators, Public Health Inspectors, and so forth. This will cost $6,028. We willalso distribute the Sinhela and/or English versions of the book among politicians, senior nurses, principalsand teachers of school, clergy of all religious denominations, and the staffs of relevant departments of theGovernment of Sri Lanka. Total number of books in English, 12,000 copies = $18,090; [i.e., $12,062 +$6,028]. Printing and distributing 22,000 black and white copies of the book in Sinhela: US $15,192

Project IIProvide Water Quality Measurement Devices [Budget: US $22,000]:

To purchase 500 units of Total Dissolve Solid (TDS) water-quality measurement electronic device from areputed company in the U.S.A., and distribute them to the 450 most affected villages, and 50 units toConsortium Volunteers for water testing during their fieldwork, enabling them and the trained-officials to dowater testing locally (please see page 5, attached line item budget). Currently, the National Water Supplyand Drainage Board (NWSDB) charges approximately Rs. 2,000 per water sample for testing (i.e., US $16per sample) and it takes about 3-weeks to get water quality results. By using this water qualitymeasurement device, the cost of water testing will be marginal, and the results of water quality and safetywill be available immediately to villagers.

Project IIIEducational Campaign, Printing 2x3 Laminated color Posters [Budget: US $50,000]:

This countrywide educational campaign would minimize environmental pollution and decrease theexcessive use and the exposure of farmers to toxic agrochemicals. As we successfully did with previouseducational efforts, we will print four different messages, 120,000; 2x3 laminated color posters anddisplays these in schools, temples, and other public places in all CKD-mfo affected areas. We will intensifythe awareness campaign involving the mass media in order to get the best results.

Project IVPoverty alleviation, job creation, disease prevention and improve nutrition [Budget: US$500,000]:Will launce region wide campaign on above areas, as these would further assist preventing CKD.

Project VDevelop & fund, a network of relevant CKD research program for local scientists in SL [US $400,000]

Project VITo purchase, install andmaintain Reverse Osmosis Plants [Budget: US $4.5 million] Thisincludes installing 450+ Reverse Osmosis (RO) water purification units in all affected villages, including thereplacement of membranes, and maintenance of RO units for 5 years. For more info about the mechanicsof RO: [http://www.ijetae.com/files/Volume3Issue12/IJETAE_1213_14.pdf]. An assumption is that in each ofthe affected villages has a ready source of water that could supply 5,000 gallons of clean water per day.

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Detailed Budget/Project Cost EstimatesSubjected to Funds Projects will be done in Parallel

Project I: Step 1: Printing cost for 12,000 copies [US $18,090]:

CKD-mfo book, 80 pages in color, Cost of printing: Rs. 175 per book ($1.35/bookThe White Paper);Costs for 8,000 books, Rs. 1,400,000; 12% VAT and 2% NBT: Rs. 168,000Total cost for printing 8,000 books = Rs. 1,568,000; [US $1 = ~Rs. 130] = US $12,060

The cost for printing total of 12,000 copies-English version of the book =US $18,090Step 2: The cost for printing all 22,000 copies-Sinhela version of the book [US $15,346]

The cost of Sinhela [to be borne by the WETF in kind] and Tamil translation = 00Printing 22,000, B&W copies of the book [Rs. 70 X 22,000] = Rs. 1,540,000

12% VAT and 2% NBT = Rs. 185,000Storage, transportation, and distribution costs = Rs. 270,000Total cost of printing and distribution of Sinhela book = Rs. 1,995,000

Cost of printing and distribution of Sinhela bookUS dollar = US $15,346

Total cost for printing English and Sinhela books[approximate dollar values] = US $33,450

Project II:To purchase, 500 Total Dissolve Solid measurement (TDS devices) [US $22,000]:

There are approximately 450 significantly affected villages in the NCP alone. We will give each village,one hand-held, sealed testing device, on the spot, water testing Total Dissolve Solid (TDS) devices. Itsbattery life is over 5,000 hours of usage. Therefore, each device will last for over ten-years. We willarrange to deliver one, water testing TDS meter to each affected village. We will train a responsibleperson in each village, such as the Village Headman/ Gramaseveka/ Gramaniladhari, or the Chairpersonof the Community-Based Organization (CBOs). Villagers will use these devices to test the suitability oftheir water supplies that they use for cooking and drinking. In addition, we will purchase 50 devices tomeasure dissolved metals and fluoride for our team of volunteers at a cost of $150 per unit.US $20.00, per TDS device, 500 cost: US $10,000;Shipping and insurance cost to Sri Lanka = US $500

At a cost of US $180.00 per metal/fluoride measurement device, for 50 devices: US $9,000Cost of distribution of testing device and educating villagers of proper use of the device = US $2,500Total cost of purchase, shipping, distribution, and training in measurements of water = US $22,000

Project III: Printing &distribution of educational/ publicity materialSinhala/Tamil [US $50,000]Printing laminated color posters: 4 different posters, 30,000 x Rs. 52 = Rs. 6,240,000 [US $48,000]Distribution, transportation, storage, and displaying costs = Rs. 350,000 [US $2,692]

Total estimated cost [approximate dollar values] = Rs. 6,350,000 [US $50,000]

Project IV: Poverty alleviation, job creation, and improve nutrition[Budget: US $500,000, over 5 yrs]:Project details /estimated line item costs will be in the website. Collaborative efforts with partner foundations.

Project V: Develop, nurture and fund a goal-oriented, network of CKD-related collaborative research programamong local academics to provide direct relief with preventive outcomes to Rajarata residents . [$400,000, over 5 yrs]:

Project VI: Purchasing and installing RO plants [US $4,500,000]

Funds to purchase, shipping, transport, install, and maintenance of high volume, 450+ Reverse Osmosis

(RO) plants in all affected villages; giving clean water that they desperately need. We are exploring othercost-effective water purification methods. Costs approximately, $8,000 x 450 RO units = US $4,500,000

The total cost the expected to raise [approximate dollar values]:US $5.5 million

Initial cost [the target] needed to complete sub-projects I, II and III are USD 105,000

Due to the extensive nature of work, we expect 15% overhead for the project [not included above]

Problem is so acute that there is urgent action needed

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Poverty Traps in Sri Lanka:

People who are reading this document areimmensely more fortunate than thousands ofpeasants living in remote areas in the NorthCentral Province (NCP). Some of them arestruggling hard to find a morsel of food to meettheir daily diet, to send their children to school

or to clothe themselves adequately. They areso defenseless against disease that more oftenthan not we hear that they expect that some oftheir children might not survive to care for theelders or even to bury them.

The information in this message is to inspire ahumanitarian appeal for affirmative actions byPoliticians, Government Servants and officers inthe fields of Agriculture, Rural Banking, AnimalHusbandry, Forestry, Community Development,Cooperative Development, Land Development,Irrigation, Local Government, Public Works,Education, Health, and Water Supply &

Drainage Board, and the like. Their positive andsynergistic actions will improve the ruralconditions of the poor. With the blessings fromthe government, we depend on the activeparticipation and generosity of Business-persons, corporate personnel, Engineers,Doctors, Teachers, Lawyers, Journalists,Priests and Monks, voluntary organizations andothers making this humanitarian project a success.

The existing poverty, epidemic of CKD-mfo andassociated premature deaths, and the diseaseburden in the NCP are outrageous. The degreeof deprivation among the poor and the prospect

of further misery for peasants are so appallingdue to inaction. Thus, the statistics of suchmeasures to provide reliefare almost irrelevant.

In fairness to those who donate voluntarily, thatinquiring as where the money goes to is areasonable question. We take steps tomaintain strict transparency when dealing withdonations, administrative work relating to thefund, and to channel the donations to thedeserving groups. At the same time, we willtake such donors preferences, interests andopinions seriously. In addition, we will beengaging the services of reputed accountingfirms to audit all transactions of the fund.

The poor in these rural communities areeconomically trapped in poverty and finding itdifficult to come out of the cycle of despair. Inorderto help them, the donors and well-wisherscould offer job opportunities and createlivelihoods through their power and resources.3

3Give a man a fish and you feed him for a day; teach a

man to fish and you feed him for a lifetime.Author unknown

Those who help can simultaneously encouragethe poor to engage in rural development workespecially in the NCP, which will result in theempowerment of women and children,minimizing poverty and eradication of CKD-mfo.

The Groups mentioned above are relatively welloff and share much in common. They are literate;their children attend good schools, and are inurban settings. They want the government toprovide them with more services, expect a longlife, eat whenever they want to, engage in lessthan optimal amounts of physical activities, readbooks of their choice, and write what and whenthey feel like, are professionally trained andeducated, live in different countries, enjoydifferent citizenships, and work in lucrativeprofessions. Considering these, we should thinkof contributing to overcome the misery andpoverty of those who are poor and suffering in Sri

Lanka. Many children and adults in the NCPsuffer from malnutrition, preventable non-communicable disease, and premature deaths,from diseases like CKD-mfo. As individuals andas Groups together, we can make a realdifference to the plight of these people. Let us domore to alleviate the suffering and misery of ourbrothers and sisters in NCP. Truly, it is now ornever.

We invite you, who are concerned with ruralsuffering and the plight of farmers dying in theNCP to analyze the ways they live, feel and act,and how these can be changed with your

intervention. Your active participation will make adifference to their life or end in premature death.

Individual and groups contributing to NCP isgood; but by joining the PHEPRO.org, collec-tively we can assist all affected people in the NCP.

Annual report on the "CKD-mfo preventionproject" implementation and the financialaudit of the PHEPRO-organization will be sentto all donors electronically. These will also beposted in the website no later than end of firstmonth of the following year. All donors willreceive a color copy of the book, "White paperon CKD."

Currently, we are finalizing the structureand the registration of the foundationPHEPRO.org. It will be responsible forthe longer-term project implementation andfinancialmanagement. Until then, HBP andWFTF together, with DVF will manage thefunctions of PHEPRO.org.

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Our extensive investigations revealed that the RO method is the mostcost-effective, environmentally friendly, scalable, and practical way ofproviding clean water to these NCP communities. With reference toRO machines, both Indian and U.S. manufactured units are availablein the market. However, the latter appears to be the better productconsidering the cost, quality of purification membranes and filters,and the durability of the machine itself. These RO machines must bemaintained through an efficient, long-term program.

Summary of Issues Related to the CKD-mfo

The Need for a Regional AwarenessCampaign and a Pollution Prevention

Program:

The availability of centrally purified, pipe-bornewater is the safest and the most cost-effectivesolution in the long term, to overcome CKD-mfo.However, this will take time. It is paramount tolaunch an island-wide awareness campaign toreduce the use of artificial chemical fertilizers andtoxic agrochemicals, and to promote their safer

use. Since the farmers are overusingagrochemicals that they are receiving cheap, agradual reduction of agro-subsidies is needed.

It is of utmost importance to initiate a regionalawareness campaign on the prevention ofenvironmental pollution. This educationalprogram will include (i) consequences of drinkingcontaminated water; (ii) prevention of watercontamination, (iii) the importance of using safe,clean treated water; (iv) water conservationmethods, (v) prevention of pollution of watersources, soil, and the environment; (vi) essentialprecautions to be taken by farmers when using

agrochemicals, and (vii) utilization of locallyavailable organic substances and compost forcultivation and pest control. We have had anongoing village-level educational campaign since2008; however, the efforts need to be intensified.

Volunteer Professionals are the MostSuitable to Carry Out This Task:

The Preventive Health, Environmental Protection,and Research Organization (PHEPRO.org),would bring expertise, expatriates and interestedlocal groups and resources together to facilitateand coordinate actions on a clear path, to provideaccess to clean water to all affected areas and

neighboring villages, and conducting a long-term,multi-disciplinary research program. Such actionwould avoid duplications; enhance the synergies,expertise, and resources to help affected people.

This simple and practical model will provide theopportunity to thousands of expatriates and thewell-wishers worldwide to contributecompassionately in tangible ways to overcomeCKD-mfo in Sri Lanka. The actions of PHEPRO

will lead to measureable and beneficial outcomeswithin the few years.

The Preventive Health, Environmental Protection,and Research Organization (PHEPRO.org) will:

a) Launch an extensive awareness campaign onprevention of environmental and soil pollution

b) Educate and encourage farmers to use lesschemical fertilizer and toxic agrochemicals

c) Help the government to reduce agrochemicalsubsidies to farmers. Educating and encouragingfarmers to accept these reductions intheir owninterest. They are surely aware that massiveover use of agrochemicals have resulted in waterand soil pollution resulting in premature deaths

d) Educate the farmers on environmental matters,pollution prevention, and the toxicity of agro-chemicals, and to provide them with protectivegear and encourage them to use such

e) Professionally install and maintain RO plants andother water purification methods in the region,which will result in providing clean water to all

affected villages within 24 monthsf) Initiate a long-term professional, real-time

surveillance program using state of the artmethods leading to timelyinterventions

g) Carry out a scientific, trulymulti-disciplinary, real-timedata collecting, geo-water,health and socioeconomicongoing research programcovering the entire region

h) Lobby the Department ofAgriculture to develop a

postgraduate trainingprograms, preferably withreputed universities abroadfor emerging young SriLankan scientists, in thefields of environment, soilscience and ecologicalaspects, including novelways to clean-up soil andwater pollution.

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Current Priorities

A regional and island-wide education andawareness campaign on prevention of water,soil and environmental pollution.

The availability of clean potable water usingRO and other methods in all affected villages.

Surveillance program and a broad-based,environmental, sociological, and medicalresearch program for CKD-mfo affected areas.

The Government needs to allocate adequatefunds and facilitate privatepublicpartnerships and collaborators with the not-for-profit sector, and facilitate the long-termmaintenance of the project in the region.

The country needs to preserve flora, fauna,and the environment, and protect thenatural resources, not only for the presentbut also for the generations to come.

A combination of sloppy farming habits,dehydration, harsh climatic conditions, andconsumption of polluted water, overuse of anti-inflammatory painkillers, use of locally brewedillegal alcohol and drugs, tobacco use, exposure

to agrochemicals and petrochemicals, andleptospirosis, all potentially contribute towards theepidemic of CKD-mfo (Figure 3). Nevertheless,some of the key plausible causes for CKD-mfo inSri Lanka have not been investigated yet.

Taken together the available data,geographical distribution of CKD-mfo, andCKD deaths, suggest that it is a multi-factorial, environmental-exposure disease.

Key observations

The CKD-mfo in Sri Lanka is an environmentalexposure disease:CKD-mfo.

Once acquired, CKD-mfo is a terminal disease forwhich palliative and other treatments are costly.Therefore, prevention is the way forward.

Providing access to potable water has a profoundimpact on controlling water-borne pathogens,toxins, and chemically induced morbidity andmortality. It is paramount to implement the mostviable, cost-effective, and sustainable waterpurification method in endemic areas; The ROmethodology currently, is the best option forproviding clean water. However, continualevaluation of new methods, and if appropriate toreplace RO Technology by including novel OzoneTechnologies and others, need to be considered.

It is essential for the country to have a MasterPlan of Water Managementand aClean Airand Clean Water Act. In addition, Governmen-tal organizations including the National WaterSupply and Drainage Board to made responsibleand accountable to the people they serve.

There is no medical solution for the prevention ofCKD-mfo. Thus, bulk of the research should befocus on prevention of the disease. Therefore,truly multi-disciplinary research should be doneincorporating agriculture, soil sciences,engineering, social sciences, and medicine.

These clinical scientific research programs shouldbe guided by the real-time data collection throughbroad-based preventive health strategies andsurveillance.

A long-term surveillance program covering clinicalcare provided locally, and a ground-baseddisease-prevention research program should beinitiated in all CKD-mfo affected areas.

Recommendations made by various groups toavoid CKD-mfo need to be properly assessedand the best systems and practices should beimplemented to resolve this disease.

Action must be taken immediately to prevent the

spread of CKD-mfo and its rising incidences inthe affected areas. Data must be collected,analyzed and especially to validate the programand to assess its outcome.

PHEPRO.org will lobby to implement the20 specific recommendations provided in the

White Paper to eradicate the poverty,malnutrition, and the CKD-mfo from the NCPand from the country.

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Additional Recommendations and Actions Needed

CKD-mfo is a terminal disease; thus, prevention isthe way ahead. It is of utmost importance to initiate aregion-wide awareness campaign on prevention ofenvironmental pollution and poverty alleviation. 4

Use of appropriate technology through education andenhancing the awareness of the disease and itsprevention, environmental pollution, and behavioralchanges must meet the needs of the villagers, andsimple, to teach and understand, and be effective.

The education messages used, whose subjects arefarmers and their families, need to be consistent and

subject to outcome validation. The use ofparticipatory rural education tools, such as socialmapping, posters, families and focus groupdiscussions should be included in this task.

Because of the diverse study designs and datacollections used, meta-analysis of data is notpossible. The continuation of future research in thesame line is unlikely to achieve useful data or identifyagents that cause CKD-mfo. Hence, it is necessary todevelop and use uniform research methodologies, before more public funds spent on CKD-mfo research.

Patients with CKD-mfo, most of whom are males, often are the primary breadwinners of households.Thus, a special government-assistance program must be implemented in the region to take care ofthose families, with special emphasis on childrens education, dietary, and nutritionalneeds.

A well-planned, continuing surveillance program and a ground-based disease-prevention research

program must be initiated in all CKD-mfo areas. These programs should be guided by state of the artmethods that lead to effective preventive health strategies. ORPHANS.Org will facilitate all these.

Develop a novel interactive patient registry and a global data-repository for CKD-mfo in Sri Lanka.

Providing prompt treatments through local clinics that provide free medications, and efforts onpreventing spread of the disease, and eliminating CKD-mfo.

Become a Part of the Preventive Health, Environmental Protection, and ResearchOrganization (PHEPRO.org), to help those who are inflicted with the disease in the NCP

Once funds are available, the PHEPRO.org will embark on this program at once, and it will provideclean water to all affected and surrounding villages in the region using RO units, within 24 months.Donating just $65 can save a life, provide family clean water for life, or educating a child/scholarship forone-year [WETF]. In addition to providing clean water, PHEPRO.org will also provide sanitary toiletfacilities. Remembering the future generations, who are more knowledgeable on environmental affairs,the Government and those who are concerned of the plight of the poor, helpless, and innocent peopleof Rajarata should undertake firm commitments that lead to sustainable and preventative action.

4Health is Wealth; The wellbeing results in higher productivity and contentment, and prosperity.

All projects will be done inparallelTimeline in accomplishing the projects:

Sub-Projects 3 months 6 months 12 months 24 months 48 month 120 months1 - White-Paper distribution

2 - Water quality-devices3 - Education of the public4 - Poverty alleviation5 - Funding CKD-research6 - Provision of clean water [ ]

7 - Outcome statistics8 - Elimination of CKD-mfo

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[]

CKD-mfo is a terminal disease; thus, prevention is the wayahead. It is of utmost importance to initiate a region-wideawareness campaign on prevention of environmental pollu-tion and poverty alleviation.4

Use of appropriate technology through education and en-hancing the awareness of the disease and its prevention, en-vironmental pollution, and behavioral changes must meet theneeds of the villagers, and simple, to teach and understand,and be effective.

The education messages used, whose subjects are farm-

ers and their families, need to be consistent and subject tooutcome validation. The use of participatory rural educationtools, such as social mapping, posters, families and focusgroup discussions should be included in this task.

Because of the diverse study designs and data collectionsused, meta-analysis of data is not possible. The continuationof future research in the same line is unlikely to achieve usefuldata or identify agents that cause CKD-mfo. Hence, it is nec-essary to develop and use uniform research methodologies,before more public funds spent on CKD-mfo research.

Patients with CKD-mfo, most of whom are males, often are the primary breadwinners of households. Thus, a specialgovernment-assistance program must be implemented in the region to take care of those families, with special emphasison childrens education, dietary, and nutritional needs.

A well-planned, continuing surveillance program and a ground-based disease-prevention research program must be

initiated in all CKD-mfo areas. These programs should be guided by state of the art methods that lead to effective pre-ventive health strategies. ORPHANS.Org will facilitate all these.

Develop a novel interactive patient registry and a global data-repository for CKD-mfo in Sri Lanka.

Providing prompt treatments through local clinics that provide free medications, and efforts on preventing spread of thedisease, and eliminating CKD-mfo.

Once funds are available, the PHEPRO.org will embark on this program at once, and it will provide clean water to all af-fected and surrounding villages in the region using RO units, within 24 months. Donating just $65 can save a life, providefamily clean water for life, or educating a child/scholarship for one-year [WETF]. In addition to providing clean water,PHEPRO.org will also provide sanitary toilet facilities. Remembering the future generations, who are more knowledgeableon environmental affairs, the Government and those who are concerned of the plight of the poor, helpless, and innocent

people of Rajarata should undertake rm commitments that lead to sustainable and preventative action.


10/1910

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SUmmARy

Non-communicable chronic diseases are es-calating in many developing countries, in-cluding Sri Lanka. Over the past 15 years,

the author has been involved in studying water con-tamination issues affecting human health and theconsequent escalation of chronic diseases, includ-ing chronic kidney disease (CKD) of multi-factorialorigin (CKD-mfo). While actively engaged in an in-

formative awareness campaign on prevention of pol-lution, he and his colleagues were also involved withthe provision of clean water to needy villages. Themain objective was to prevent the occurrence of newcases of CKD. This oration summarizes the writersndings and interpretation of the data available todate and actions need to prevent this dangerousepidemic affecting the farming communities and theeconomy and soon reaching pandemic proportions.

While a number of groups have been investigatingthis issue over the past ve years, there has beenconsiderable confusion and controversy about theinvestigational methodologies employed, dispari-ties of ndings, interpretation of data, and conclu-sions. Attention has been diverted from seriouswater pollution issues related to heavy metals, uo-ride/hard water, pesticides and chemical fertilizer,to secondary factors, such as algae and poisoningof North Central Province bordering villages by for-mer terrorist groups who previously inuenced thearea. In fact, none of these mentioned factors attheir reported levels of contamination could singly

cause renal failure of this magnitude or explain itsgeographical distribution.

However, little or no attention has been paid to sev-eral other plausible causes of nephrotoxicity (toxicagents that can harm kidneys) in the affected areas.These include the overuse of nephrotoxic non-ste-roidal anti-inammatory agents (i.e., most painkill-ers, except paracetamol), the use of illicit drugs and

alcohol, smoking using locally grown tobacco, lackof safe working conditions in the dry zone regions(including drinking lesser amounts of water, but wa-ter that contains pollutants), petrochemical contami-nation of water sources, leptospirosis, and others.

The author concludes that the CKD in the dry zonein Sri Lanka is an environmental exposure diseasecaused by multiple factors acting togetherthusthe terminology CKD-mfo. Nevertheless, the over-all situation suggests that the aetiology of CKD-mfois not that complicated, and the solutions neededare straightforward.

Bue Prin:To prevent CKD-mfo, it is essential totake prompt actions to: (a) educate farmers on pre-vention of water and environmental pollution andtaking proper safety precautions when handling ag-rochemicals and petrochemicals, (b) provide accessto clean and safe potable water, and (c) embark ona broad-based, cause-oriented, environmental andsociological research program covering the entire

region. In addition to implementing a well-coordi-nated synergistic plan, to prevent healthy farmersfalling victims to renal failure (i.e., acquiring CKD-mfo), premature death, and massive family disrup-tions, the programme must include all stakeholdersto maximize resource utilization, preferably usingthe philanthropic and private sectors.

PREAmBlE:

This oration is in honour ofand dedicated to the vision

and far-sightedness of thefounder of Ananda CollegeCoone Henr Seee O-

co. He left behind a legacyof immense accomplish-ments in many elds, includ-ing education, agriculture

law and order, diplomacy, and journalism. He wasa great visionary, a philanthropist of the highest de-

Oco meoria Oraion2013Waer Pouion-Associaed I Heah:

Specia Ephasis on Chronic Kidne Disease in Sri lanka

b Proessor Suni J. Wiaawansa, mD, PhD, mBA, DSc

Unied Saes o Aerica

11

1 Kularatna Hall, Ananda College, Colombo 10, Sri Lanka; November 30, 2013; [email protected] Organized by the Ananda College Old Boys Association, Colombo, Sri Lanka; www.Wiaawansa.or

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gree, who dedicated his entire life to the peace andwelfare of his fellow human beings (volunteerism).

All this he did for humanity in general and not forpersonal gain. He set the bar high for all of us byhis seless dedication in the service of humankind.

WAtER IS A HUmAN RIgHt:

Accessible and affordable clean water is a fun-

damental human need and a basic human right.Clean water and sanitation can make or breakhuman development and societal survival. Wateris fundamental for all us; our health, capabilities,and what we can become. Next to oxygen, water isthe most essential component required for all lifeon earth. In fact, without clean water, human andanimal life is unsustainable. The failure to investnancial and political capital for improving cleanwater supplies will lead to loss of fundamental op-portunities for social and economic progress, and

pave the way for disharmony, unhappiness, andloss of productivity.

Access to clean water is also an important indi-cator of human progress and healthy growth in acountry. In fact, life expectancy in any country isdirectly related to the availability of clean water andsafe sanitary facilities, rather than to economic orstructural development, or medical or materialisticcomforts and advancements. Water polluted withmicrobes causes noticeable diarrhoeal diseases,whereas chemical and toxin contaminations make

people chronically sick and kill them insidiously.Toxic chemicals or disease-causing organisms af-fecting health are microscopic and can be neithertasted nor smelled. Although people judge the qual-ity of water by taste, odour, and appearance, thesethree factors provide no information on the healthrisks that drinking water might portend.

ClEAN WAtER tAKEN

fOR gRANtED:

Even today, for more than two billion people, cleanwater is not a readily accessible commodity, eventhough it is a basic human requirement. Moreover,approximately 2.4 billion people still have no accessto proper and safe sanitation; most of the time thesetwo conditions co-exist. In addition to water wars, theglobal water crisis has led to worsening incidencesof diarrhoea and deaths, especially in economical-ly deprived countries. Consequently, close to eightmillion people, including three million children, dieevery year of illnesses related to unsafe water and

poor sanitation alone, which is far more than fromany other single disease in the world.

There are two kinds of common water contamina-tions: microbial and chemical toxins. Most peopleare familiar with sewage and bacterial water pollu-tion leading to dysenteries. Microbial contaminationcan be puried relatively easily by chemical disin-fectants (e.g., chlorine), certain ltration methods

or by boiling, but it is difcult to dispose of chemicapollutants. Considering the massive scale, solvingthis is not a simple matter: it needs funds but alsoa humanistic approach, political will and courageand proper setting of the priorities. To make it sus-tainable and cost-effective, the water and sanita-tion crisis must be addressed through privatepub-lic partnerships with all stakeholders together, withrm commitment from the government.

Most people, especially in the economically ad-vanced countries, take water for granted: theyturn on the tap and the water flows or they pur-chase dozens of bottles of water from the locasupermarket. They forget that 40 to 50 years agoall these countries were no better than the cur-rently emerging economies. The difference is thatleadership in these countries at some point madethe right decision to establish purified pipe-bornewater supplies and safe sanitation to the major-ity of their compatriots and initiated enforcementof environmental protection laws. These are themost important factors in improving human health

and advancing the longevity of populations in acountry. The outcomes on health and longevityfrom these actions are more powerful than all sci-entific discoveries and innovations and medicaadvances combined.

glOBAlIzAtION AND

PRIvAtIzAtIONS:

During the past three decades, privatization waswidely advocated worldwide as a solution to the

failures of the public sector. It was presumed thatthe private nancial capital and the utilities wouldcreate efciency, generate new jobs, and providegreater accountability. However, the expected out-come proved to be otherwise. Private provision didnot turn out to be the magic solution in many coun-tries. The expected efciency, nance, and gover-nance through the private sector at times did notbear fruit. In recent years, many of these privatizations failed miserably, in part because of miscalcu-lations, greed, and corruption.

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Meanwhile, the troubles associated with the publicsector and in certain cases the private sector, contin-ued. These include inefciency, lack of accountabil-ity, corruption, mishandling of resources, and inequi-ty. In the case of water, low-cost water was divertedto high-income groups, and low-quality service (orno water) was provided to the poor. Lack of waterand water-borne diseases mostly affect poorer com-munities. Thus, worldwide most of the privatised wa-

ter enterprises that failed led to more suffering of thepoor, those with little or no voice. From the perspec-tive of poor village households, the question of therelative virtues of public versus private sector per-formance has been only a distraction from concernsthat are more fundamental: the inequalities and in-adequate performance of public and private watersupply sectors. Briey, water is a national resourcethat should not be privatized in Sri Lanka.

fOllOW tHE mIDDlE PAtH:

Any extreme is not only unwise but also unsustain-able. High subsidy and the agro advertising encour-age farmers to over-use pesticides and chemicalfertilizers. Over-use of agrochemicals and environ-mentally and economically destructive agriculturalpractices are unsustainable in the long term, aswe have witnessed in the North Central Province(NCP) and the NC region (NCR); yet little or no pre-ventative action has been taken. Continuing wilfuldestruction of the environment further damages thesoil and water sources, which will harm the pres-

ent and future generations. Resolving such com-plex ethical, social, and cultural issues at an earlystage is highly desirable, rather than having to paymillions of rupees in attempts to eliminate the prob-lems once they are well established.

Globalization, tempting advertisements, and rapidtechnological advances arouse desires, which areunquenchable. The sectarian increase of wealth in-creases the gap between the poor and the rich andexerts undue pressure on the middle class, whichadds to the ever-increasing unhealthful stress lev-

els. These will negatively affect societal harmonyand the health and well-being of the population.Moreover, such problems escalate global distur-bances and disharmony; add to destructive war-fare, economic disruptions, widespread corruption,global warming and major climatic changes; anddisrupt the peace and fabric of society.

The above-mentioned are further reasons why weshould focus on The Buddhas teachings, particu-larly staying in the present moment and following

the Middle Path, the path that leads to compassionsharing, satisfaction, and everlasting happiness. Inpart, the escalating CKD epidemic is due to greedand a lack of understanding of reality. Buddhistmeditation practices and mental training facilitateachieving contentment. Imagine the majority of peo-ple in the world practising these, in any mainstreamreligious doctrine. It would revolutionize the lives onearth today. However, nothing will work unless there

is a genuine desire to change our lives by adoptingnew healthful habits, sharing resources, eating ahealthy diet, engaging in physical activities, practis-ing regular meditation, genuinely following the FivePrecepts, ridding ourselves of greed and jealousyand learning to see the world as it is.

mINDfUlNESS AND tHE

gROSS DOmEStIC HAPPINESS:

Sustained happiness is achieved through mindful-

ness (samma sati) and generosity. Mindfulness trainsus to become conscious of things, as they really ex-ist. Mindfulness facilitates progressing through self-discipline and mind controla gentle and graduaprocess leading to the elimination of attachmentscravings, and suffering. However, a strong determi-nation is needed to overcome the overriding desiresand harmful habitsto oneself and toward othersYou can protect your health by practicing good hab-its; but you cannot buy good health.

One cannot purchase happiness or sustainablepeace. No one can bestow happiness to you; youmust create your own well-being and discover hap-piness within yourself. Despite the large plots offarmland where you cultivate paddy, you can con-sume only a plate of rice; of a dozen mansions youmay own, you need only one room to sleep in; ofseveral cars you may have, you can drive only oneat a time! Thus, when you have just enough foodand money to spend, a safe roof to live under, andaccess to basic human needs, that should satisfyyou. Do the farmers in Rajarata have the facilities

and comforts that you have? You should considerspending at least part of your remaining time andresources for the benet of others and supportingthose in need. Rational thinking tells us that we donot need to hold on to our greed and the desiresto have more and to compete with others to ac-quire more materialistic wealth. More you give uphappier you will be. Giving up comforts (such) wilmake the mind lighter and happier. It will elevateyou from the mundane to the sublime, thus makingyou god-like (divine).

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CHRONIC KIDNEy DISEASE

(CKD) IN RAJA RAtA:

Over the past two decades, the incidence of sev-eral chronic non-communicable diseases (NCDs),such as cancer, heart diseases, and CKD, have in-creased in many developing countries, while the in-cidence of communicable diseases is decreasing.

A high incidence of chronic renal failure (disease)

of an unusual nature (CKDu) exists, originating inagricultural communities in several dry zone areasin the world. One specic example is CKD of multi-factorial origin (CKD-o), which is affecting theNCP and other districts in Sri Lanka. However, thiscondition is not unique to Sri Lanka. The high in-cidence of CKD-mfo has been reported in severalother dry-zonal agricultural societies, as has Bal-kan nephropathy, Kashin-Beck nephropathy China,La Isla Chichigalpa, and South American CKD ofunknown origin (CKDuo).

To date no specic cause is identied for CKD-mfoin Sri Lanka, but a multitude of potential toxic pollut-ants have been suggested, including heavy metals,cadmium, arsenic and lead; uoride and hard water;and ionic-concentration of water, chemical fertilizersand toxic agro-chemicals, but the cause of CKD-mfois not clear. To-date, CKD-mfo is not linked to anincident, event, organism, or component. Data aresufcient only to make hypotheses, not conclusions.It is highly unlikely that a single component is re-sponsible for causing this CKD-mfo epidemic.

tHE COURSE Of CKD:

The development of CKD is insidious; by the timeit manifests clinically, advanced pathological and ir-reversible damage has occurred in kidneys. Oncethe damage is done, it is difcult or impossible toreverse. Dialysis only slows the deterioration andpostpones death. Meanwhile, other NCDs, includ-ing diabetes, hypertension, and depression, mayco-exist with CKD. Because the causes of CKD-

mfo are multiple, a single-cause hypothesis or re-search program to prove such is unlikely to gener-ate meaningful data or provide useful evidence tocurb CKD.

CKD-mfo is most likely due to a combination of fac-tors, and when the right adverse conditions exist,kidney failure occurs. Nevertheless, there are otherserious but preventable potential sources prevail-ing in the region that have not been addressed todate. These include the over-use of non-steroidal

anti-inammatory analgesic agents, consumptionof illegal drugs and alcohol, smoking locally growntobacco that contain higher amounts of heavy met-als, leptospirosis, excessive exposure to petro-chemicals, exposure to harsh climatic conditions inthe eld, chronic dehydration and continually drinking concentrated (in part due to drought) pollutedwater, at times from the paddy elds. It is most likelythat a combination of some of the above-mentioned

components is precipitating the CKD-mfo.

gEOg RAPHIC Al PAttERNS

AND tHE vUlNERABIlIty

fOR CKD:

The potential CKD-mfo area covers approximately20,000 km2, with a population of about 2.8 millionHowever, this vulnerability and associated risks arelikely to increase with time in the absence of deni-tive preventative actions. The accelerated Mahave-

li project has led to bypassing the ancient irriga-tion system with fast-owing man-made canals thaadd to soil and ecological erosion, changing theareas biodiversity and facilitating silting of tanksThis necessitates frequent dredging of reservoirsin the NCR, which allows re-exposure of deeply de-posited heavy metals and other contaminants overcenturies, and the potential for them to enter intothe dynamic water systems; thus, contaminatingthe human food chain. In the short term, these newdevelopments are protable, but they have long-term negative environmental consequences andadverse health effects. Similar issues are likely tooccur in Southern region.

Water contamination is not new to Sri Lanka. De-forestation of hill country, industrialization and colo-nization of former forest areas in the NCP for set-tlements, further add to the environmental stressWithout adequate planning for potable water, drain-age, and sanitation, these human settlements wouldinict tremendous pressure on the environmentand continue to have adverse impacts on freshwa-

ter systems and thus on human health. Uncoordi-nated planning has led to surface and groundwatecontamination with nutrients (nitrate/nitrites, phos-phates, and organic matter), toxic chemicals, andother unhealthy substances. Unfortunately, this hasworsened due to haphazard and overuse of agro-chemical and other pollutants by farmers.

None of the proposed putative substances explainsthe geographical distribution with the prevalence oCKD-mfo. The closest would be the uoride. Nev-

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ertheless, taken together the geographical distribu-tion of CKD-mfo and CKD deaths suggest that itis a multi-factorial environmental exposure dis-ease. Poor farming habits, dehydration, harsh cli-matic conditions, continually drinking concentratedchemically polluted water, indulgence with anti-in-ammatory painkillers, use of illegal alcohol, tobac-co use, exposure to agrochemicals and petrochem-icals, and leptospirosis; a combination of these can

potentially contribute to the epidemic of CKD-mfo.A single factor alone is unlikely to be responsible.Nevertheless, most of the above-mentioned plausi-ble causes for CKD-mfo in Sri Lanka have not beeninvestigated to date.

While arsenic is an ubiquitous air and soil contami-nant, groundwater contamination with uoride andcadmium is less common, as is water hardness.The levels of pollutants in water are small and varymuch within a region; a single-cause hypothesis isimprobable. Moreover, water quality varies within

a few kilometres in any region and from village tovillage, and the CKD-mfoaffected villages are lo-cated alongside non-affected villages within shortdistances. Considering the mosaic geographicaldistribution of CKD-mfo, it is likely that the geo-wa-ter environment is contributing to the epidemic inSri Lanka. Whether it is due to natural evolution orfabrication is to be determined. The priority shouldnot to debate who is right but saving lives.

The prevalence of CKD in Sri Lanka is geographi-

cally demarcated but gradually spreading to adjoin-ing areas in NCP and also to distant areas, suchas the Badulla and Hambantota districts. Moreover,the distribution of patients with CKD is not uniformthe prevalence is non-contiguous. Most affectedare in agricultural areas, in which more than 90% ofthe population lives in rural communities with littleaccess to modern amenities, safe potable water,sanitation, and medical facilities. This disease anddeaths primarily affects young to middle-age malefarmers. Thus, already some villages have only ahandful of surviving middle-age men.

PRACtI CAl WAy fO RWARD

tO CURB CKD-mfO:

There is no doubt that the provision of centrallypuried, pipe-borne water is the best, safest, andmost cost-effective solution in the long term. If pre-mature deaths due to CKD continue at the currentrate in the NCP, by the year 2040 there will be lessthan 10% of adult males living in the entire NCP

region. This not only would devastate families bualso would markedly changes the demographicsand adversely affect the countrys rice sufciencyand the economy.

Over the past fourteen years, the author has triedto persuade successive governments to earmarkan additional 10% for funding for pipe-borne water-related infrastructure expansion for the NCP and

other remote localities; but this plan has not ma-terialized. With the current approximate 1% effortit may take over 50 years before the Water SupplyBoard is able to provide pipe-borne water to theseregions. Even with the allocation of an extra 10%per year, earmarked funding for infrastructure ex-pansion, it may take 20 to 25 years before mostpeople in the region have access to a centrally pu-ried, pipe-borne, clean water supply. However, bythen, we may witness another 200,000 deaths dueto CKD-mfo. Even today, a number of families inthe NCP have no living adult males in their house-

holds because of CKD. Thus, we must provide asustainable interim solution for providing clean wa-ter to the NCP residents.

Delay in implementing a rm solution promote deathsof farmers and negatively affects the rice productionin the region, as happened after the Chola invasionin the same region hundreds of years ago. On thecontrary, to some recent stories, the abandonmenof Rajarata was not due to failures of the ancient ag-ricultural system, but to the destruction of hundreds

of ancient cascade reservoirs by the Chola invadersThis led to an epidemic of mosquito-borne diseasesparticularly malaria that forced Rajarata residentsto vacate the territory. Unless we take rm actionsnow, a similar calamity and abandoning Rajaratacan happen again due to CKD-mfo. Would the gov-ernment and the rest of the country continue to beblind to this matter?

Collectively, we failed to implement solutions a de-cade ago to prevent deaths and the spread of thisdeadly disaster that is currently wiping out a large

number of families and destroying the breadbas-ket of Sri Lanka. However, using technology wecan reverse this trend. In addition to controllingagrochemicals and decreasing agro subsidy, it isnecessary to provide region-wide intense educa-tion program on prevention of water pollution, andarrange a sustainable and affordable method toprovide clean water to affected villages. Postpon-ing taking definitive actions or waiting until a hy-pothetical cause for the CKD-mfo discovered isunconscionable.

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Agriculture is a matter of public interest. It is notmerely a way of making money by raising cropsor merely an industry or a business; it has to bea public function or service performed by farmersto secure a living for themselves, while providingfood for the population, caring and using the landresponsibly for the national interest. Thus, agri-culture should be considered no different from thepublic services provided by teachers, public ser-

vants, or physicians. The government and its insti-tutions, such as the departments and corporationsand other entities that are interlinked to agriculture,health, the environment, economy and national de-velopment, must take full responsibility not only foragriculture and the environment, but also for thewell-being of people and the long-term sustainabil-ity of the countrys population at large.

WAtER S OURCES A ND

qUAlIty:

Drinking water, both tap and bottled, come fromrivers, reservoirs, lakes, ponds, streams, springs,and wells. When rainwater and surface water travelover the ground, it collects contaminants, includingnaturally occurring substances such as mineralsas well as manmade contaminants such as agro-and petro-chemicals, household and commercialdisposals, and human and animal waste. Conse-quently, all drinking water sources contain certainamounts of contaminants. At low concentrations,these contaminants do not harm living beings.Environmental protection agencies of each coun-try provide standards and regulate the amounts ofcontaminants allowable in drinking water. Thesestandards must be strictly adhered to and applyequally to the NCP and all affected areas, as wellas across the country.

Inorganic contaminants, including heavy metals oc-cur naturally and because of storm-water runoffs,industrial or domestic wastewater discharges, gasand oil production, mining, or farming. Pesticides,

herbicides, and other toxic components come froma variety of sources, including agriculture, urbanstorm-water runoff, and residential waste. Addition-al contaminants include organic chemicals, factorydischarges, by-products of industrial processingand petroleum production, gasoline waste from ve-hicles and stations, radioactive contaminants, ur-ban storm-water runoff, and septic tank systems.The inadequacy in environmental pollution controland virtual lack of implementing existing laws addto the problem.

lONg-tERm StRAtEgIES AND

ENvIRONmENtAlly fRIENDly

AgRICUltURAl mEtHODS:

In parallel to the above-mentioned preventativestrategies, agricultural research programs shouldfocus on generating naturally pest-resistant, high-yielding seed varieties and ones that thrive on

compost and other natural fertilizing methods. Inaddition, the government needs to embark on re-constructing the thousands of abandoned or par-tially used cascade tanks and ancient irrigationsystems, restoring the natural environment, pre-venting growth of mosquitoes and other harmfupests, encouraging farmers to use natural methodsand the minimum necessary use of agrochemicalsintroducing environmentally friendly agriculturamethods, minimizing environment pollution, andencouraging soil and water conservation. All thesemust be a part of the long-term strategy to improve

the health, wealth, well-being, and prosperity of thenation (food + agriculture + clean water + healthyenvironment = Health). Water and clean environ-ment are national treasures; thus, everyone hasthe responsibility to protect them.

Currently, contribution from the farmers to agriculture and the economy is much more than the receneconomy generated through highly visible infra-structure developments. Yet the distribution chan-nels for their products have not adequately attend-

ed to nor improved. It is important that farmers areprovided with the right value for their products; itwill stimulate spending and the growth (GDP), thusenhancing the economy. It would also decrease thepressure on farmers to produce more by over-useof agro-chemicals and polluting the environment.

tHE P RACtICA l WAy

fORWARD:

The Preventive Health, Environmental Protection

and Research Organization (PHEPRO), that con-sists of expatriate organizations and local organi-zations is set up to maximize utilization of humanand material resources, raise funds, and imple-ment a broader project to help NCP residentsSuch a unied organization would bring expertiseand resources of expatriate and local groups andresources together, facilitate and coordinate ac-tions on a clear path to implement an awarenessprogram and provide safe and clean drinking wateto all affected areas and neighbouring villages.

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Moreover, this would avoid duplications, focus onthe matter at hand, and truly offer a multi-disciplin-ary approach on key issues for the villagers andminimize incidence of CKD-mfo and prevent CKD-deaths. PHEPRO will synergize the working pro-cess; bring expertise and resources to help thosewho are in need in Rajarata and elsewhere in thecountry. Contingent upon funding, PHEPRO willcoordinate systematically the implementation of

the programs of public education and effectivelyprovide clean water to all affected regions, as perthe set goals.

In addition to multi-disciplinary research program,this practical model provides the opportunity forthousands of concerned expatriates to adopt vil-lages and to contribute in a meaningful way to pre-vent farmers succumbing to CKD-mfo. When fundsare available, clean water is provided to the all af-fected region within two years. Once the proposalis implemented fully, it will stop or at least markedlydecrease the incidence of CKD-mfo in farmers (i.e.,new patients acquiring CKD-mfo) within the nextve years. That will give an adequate breathingspace for the national Water Supply Board to placenecessary infrastructure to provide pipe-borne wa-ter supplies to the region: the focus of the WaterBoard (i.e., a sustainable long-term solution).

PROvISION Of ClEAN WAtER:

In addition to the provision of clean water, it is es-sential to train all farmers the correct and safe waysto use pesticides, herbicides and fertilizer and takeprecautions on preventing exposure to concen-trated doses of these chemicals. Good habits suchas correct disposal of used utensils, the use ofprotective gear, and the use only of manufacturerrecommended levels of chemicals, encouragednot to use waterways to clean tractors and otherpetrochemical-driven agricultural equipment, andenforcement to stop it. In parallel, it is necessaryto provide a disincentive to prevent farmers over-

using agrochemicals by gradual removal of the ag-rochemical subsidies.

In contrast to the modern farming methods, tradi-tional farming used little toxic chemicals, and mostmaterials were recycled, thus enriching the environ-ment. The country must start bridging the gap be-tween modern and traditional agricultural methods;they can go hand in hand. Agriculture must encom-pass a clear and unquestionable public interest andmove toward the goals of sustainability, promoting

public health, and self-sufciency. We need a newvision of culturally and economically acceptable andenvironmentally sustainable agriculture methods.

WAtER PURIfI CAtION:

None of the domestic water purication units cur-rently sold in Sri Lanka are efcient in removing alpotential contaminants to a meaningful level; thus

they have no place in preventing CKD-mfo in SrLanka. Over the past three years, the experimentsconducted by the author in his laboratory usingthese lters failed to conrm lter efciency in re-moval of potential pollutants. A new, sustainablereliable, and scalable water purication and supplymethod is necessary. One such method is reverseosmosis (RO).

REvERSE OSmOSIS

tECHNOlOgy:

Reverse osmosis is a widely used mechanicawater purification method. By applying hydraulicpressure to the polluted side of compartmental-ized water, clean water is forced through a finemembrane. The process also removes solublecompounds and all particulate matter, includingsalt, heavy metals, fluoride, and agrochemicalsfrom brackish water. Reverse osmosis is usedin multiple industries, including recycling, hospi-tals, wastewater treatment, and the milk, foodand beverage industries. With well-calibrated andproperly selected membranes, stand-alone ROsystems generate continuous clean and pure wa-ter with little running costs for long periods.

However, no two RO systems sold are alike in qual-ity. The quality of RO system membranes varies alot. Selection of the right RO unit depends on a num-ber of factors, including the quality of contaminatedwater, its hardness, and the amounts of total dis-solved solids (TDS), ionocity, oxidising componentschloride, conductivity, water temperature, the pH

and the volume demand for clean water. Thereforeto be successful in providing clean water and for thedurability of the RO membranes (the most expen-sive part of an RO unit), it is critical to maintain iproperly, identify the right RO separation membraneand correct pre-lters for a given village.

The RO plants need electricity to run their pumps,powered from either grid-based electricity or solarenergy. RO technology is the most efcient, cost-effective, and practical way to remove all potentia

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water contaminants and thus is the best interimsolution to provide clean water to communities inRajarata in a sustainable and affordable manner.None of the current ltration processes removesall potential water contaminants. In the absence ofthe provision of clean water, the incidences of CKDwill continue to increase. Despite the relatively highinitial capital costs of RO units, they would provideaffordable clean water in a sustainable way for

~25 years. Provision of clean water would preventCKD-mfo and premature deaths and mandate theWater Supply Board to provide pipe-borne water tothe entire NCP and other regions.

PRACtICAl WAy fORWARD tO

CURB CKD-mfO:

There is no doubt that the provision of centrallypurified pipe-borne water by the Water Board orby the private sector is the best solution for the

affected regions in Sri Lanka. Depending on thegovernmental fund allocation and the efficiency ofconstruction, it may take three decades or morefor such to materialize. The above-mentioned isachievable in the near future, if the governmentearmarks an additional 10% (or more) per year forthe national water and drainage budget, specifi-cally dedicated for infrastructure development forthis region. The supply of bottled water or dailytransportation of water via bowsers, as currentlypractice, are two of the most expensive, environ-mentally unfriendly, and unsustainable remediesfor providing water to any given community andthus, should not be encouraged or pursued.

A unified organization like PHEPRO would bringexpertise, expatriates, and interested local groupsand resources together to facilitate and coordi-nate actions on a clear path, including awarenessprograms, the provision of safe, clean drinkingwater to affected areas and neighbouring villageswill and conduct a long-term, multi-disciplinaryresearch program. It would avoid wasteful dupli-

cation, and synergize expertise and resources tohelp those in need.

This simple and practical model will provide theopportunity for thousands of expatriates and well-wishers worldwide to contribute compassionatelyin tangible way to help overcome CKD-mfo in SriLanka. PHEPRO will lead to measureable, tangi-ble, and benecial outcomes within the next sevenyears, while waiting the Water Board to providepipe-borne water supply.

WHAt IS mISSINg?

Public spending has a central role in nancing theextension of water systems to poor householdsCurrently, there are few publicprivate partner-ships to overcome the CKD issue or to improveany healthcare delivery in Sri Lanka. Urgent anda fundamental attention are needed in this ne-glected area to synergise the efforts and to maxi-

mize utilization of resources. The potential role focross-subsidies and transfer from higher-income tolower-income users in utility pricing is worth explor-ing. The adaptive systems need customizing for thecountry and for a given community. High-priced water is not in the interest of public health.

Pure water is in abundance, but it must be madeavailable at a price within the reach of all. Coreattributes of water security, sufciency, safety, ac-ceptability, accessibility, and affordability shouldrecognize when providing domestic water supplyand must be addressed in all districts, regardlessof whether they are urban or remotely located com-munities in the country. The water-sanitation dis-connect delays the progress of a society. There-fore, sanitation and sanitary practices must givenattention in parallel. It is not possible to sustain onewithout attending to the other. In addition, we needto incorporate a broad-based, environmental (soil-water-air) and socio-economic research programcovering the area affected by CKD-mfo. Such aprogram is likely to reveal various ways of how we

can prevent a similar calamity in the future.

CONClUSIONS:

Water security has become a global threat, espe-cially with the on-going unprecedented climaticchanges and its environmental impacts, includingon potable water. Cycles of ooding and droughtsrising sea levels and frequent storms, hurricanesand typhoons, together with over-population in cer-tain areas add to water contamination, sanitary is-

sues, and water security.

Provision of access to clean water is one of thegreatest challenges facing most of the economi-cally disadvantaged countries in this millenniumWater insecurity leads not only to poverty and sick-ness but also to water wars. The implementation ofthe new millennium goals and the Universal Decla-ration of Human Rights include, among others, theprovision of clean water. Yet the progress aroundthe world is too slow and inadequate. Consequent

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ly, one fourth of the worlds population has no ac-cess to this vital life-saving commodity.

Many are still unaware that over a third of the wa-ter-related deaths are due to non-bacterial waterpollution: consumption of water contaminated withchemicals and toxins. These chemicals and toxicagents enter the human body through oral, inha-lational routes, or via the skin, and exert negative

effects on all organ systems, including the kidneys.Unfortunately, exposure to toxic agents in the natu-ral and occupational environments has become acommon occurrence. Ingestion of heavy metals,such as lead, cadmium, arsenic, and uoride, andagro-chemicals, such as pesticides, herbicides,and fungicides, increases the morbidity and mortal-ity of the exposed individuals. Such contaminationslead to many chronic diseases, including CKD, liverdisease, cardiovascular diseases, infertility, devel-opmental disorders, and brain disorders.

Access to potable drinking water has a profoundimpact on controlling water-borne pathogens andtoxins and chemical-induced morbidity and mor-tality; these are preventable causes of deaths.These include diarrhoea and dysentery, and chem-ical-induced ailments, especially in the vulnerablegroups. No intervention has greater overall impacton national development and public health than theprovision of safe drinking water and the proper dis-posal of human waste.

There are increasing concerns about the health im-pacts of climate changes, water and air pollution,global warming, and ecosystem degradation. Over-utilization of the nite reserves of non-renewable en-ergy, and the accumulation of waste, and the misuseof water resources further compromise the availabil-ity of potable water. While conventional wisdom isgood, conventional thinking may not be healthy oreven appropriate, especially in times of crisis. Newparadigms should explore on adapting to changingsituations and prompt actions to be taken.

To be successful, no matter what profession or in-dustry you are in, education and skills training areneeded to develop with an inquisitive mind; theseare encouraged in Buddhist teachings. A system ofintegration of skills for innovations and inventionscoupled with ethical leadership possessing product/services management skills are imperative in gen-erating new inventions. The great volunteer, Colo-nel Henry Steele Olcott was endowed with all thesegreat qualities. These are applicable whether youare in education, services, production, or in sales.

Col. Olcott was a broad-minded practical manan expert in agriculture. If he were alive today, hewould recommend a similar plan indicated above toovercome the CKD-mfo affecting Rajarata.

HOW CAN yOU BE A PARt O f

tHE SOlUtION? PlEASE

JOIN US fOR

A) Island-wide campaign on prevention of watercontamination and environmental pollution.

B) Provision of clean and safe water using ROsystems to all CKD-affected villages in Hela.

C) Broad-based environmental and socio-economic research program in CKD affected areas

D) Taking part in raising funds and developing col-laborations and partnerships with non-protsand the private sectors to implement the projecand achieve its longer-term goals in NCR.

Once funds are available, PHEPRO.org will instalRO plants within 18 to 24 months to provide cleanwater to all affected villages in the NCP. In addi-tion to providing clean water, the project should em-brace provision of toilet facilities. We ook orwardo eaninu discussions, underakin r

coiens b ou and he oernen, ead-

in o susainabe acion.

Let us all join hands, the learned and the not so

learned, the mighty and the meek, the rich and thepoor, the Buddhist and the Christian, the Muslimand the Hindu to safeguard Hela, our only Home-land. The land you love and cherish, the land youvalue most, in order that we all live and let live. Sothat we are able to leave a better world for genera-tions of our descendants!

www.wiaawansa.or

W I M A L A W A N S A

F O U N D A T I O NOpening Doors for Healthier Life.
http://wimalawansa.org/http://wimalawansa.org/

Documents

CKD Flyer PHEPRO.org Sri Lanka