Sunday Times 2
Kidney disease in NCP: Focus on prevention
Chronic kidney disease of multi-factorial origin (CKDmfo) is an environmentally acquired, occupational disease in which the cause is still not understood. However, consumption of polluted water seems to be the underlying reason. Water that is contaminated with multiple toxic agents (hence multi-factorial nature of origin) and sources seems most likely causing this deadly disease.
To date, there is no scientific evidence that the food produced in the North Central Province (NCP) has any of the postulated contaminants or toxic contents exceeding the WHO stipulated levels. Current data suggest that the food produced from the NCP has no excess pollutants compared with food obtained from the other parts of the country. Therefore, contrary to the false propaganda and speculations, to date, the food produced in the NCP is safe to eat. Nevertheless, the respective branch of the Health Department must be vigilant and need to proactively test food samples on a regular basis.
The inability to diagnose CKDmfo early
A patient receives dialysis treatment at Anuradhapura General Hospital. Photo credit: Anna Barry-Jester/ecowatch.com
Early diagnosis and intervention is most important to prevent premature deaths of those affected by CKDmfo. However, the methods that are recommended and are being used by the Department of Health for screening and diagnosis of CKDmfo in Sri Lanka, only detect less than 40% of those who are affected.
Because of this lack of sensitivity and specificity of the current methods used, the diagnosis of renal impairment is made infrequently among the affected and it is often made too late. Consequently, even at the time of the diagnosis, many of these patients are already in an advanced stage, requiring renal dialysis (see the picture of kidneys). The delay in diagnosing the disease causes not only the inability to recover their renal function of these patients through cost-effective treatment, but also makes patients dependent on expensive dialysis, and the loss of productivity and associated major opportunity costs (loss of more than 1.5 billion rupees per year) and make them economically unproductive and impoverished.
No medical solution to prevent CKDmfo
To date, there is no single medical solution for preventing this disease, and the Government has not taken substantive action to prevent it from spreading. Consequently, younger farmers are now being affected by this fatal disease at an alarming rate. Moreover, the disease is now spreading to far away regions, such as Badulla, Udawalawe, Vavunia and Jaffna.
The Health Ministry and the Department are responsible for the treatment of patients with CKDmfo and alleviation of rampant malnutrition in the NCP. However, other than implementing a region wide, effective surveillance programme, they can do little on prevention. In comparison with various other ministries and departments, the role of the Department of Health is minor in preventing this serious disease.
Consequently, it is a mistake that the Ministry of Health and the Department of Health trying to “grab” the CKDmfo prevention programme(s), where they have little role to play. The Health Ministry and the Department should focus on their co-competences: efforts on taking medical care of CKDmfo affected people, conducting cost-effective screening programmes and early diagnosis using right diagnostic methodologies, and overcome malnutrition, throughout the affected regions. Reliance on the use of micro-albumin creatinine ratio (MCR) for screening and diagnosis (as it is recommended by the Department of Health) would only identify less than 40% of the affected people, and the diagnosis is made too late.
Governmental stakeholders
A number of ministries, departments and authorities dealing with agriculture, irrigation, environment, education, rural development, local governments, social services, law and order and justice have more responsibilities than the Ministry of Health in preventing CKDmfo. Therefore, these authorities must take their own focussed initiatives in conjunction with other departments to implement complementary, region wide educational and pollution prevention programmes. The Central Environmental Authority in conjunction with the Ministry of Law and Order must bring violators of water, air, and environment to justice.
Steps to prevent CKDmfo
The provision of clean water would reduce CKDmfo incidence and deaths, but only by about 45%. To significantly control the disease, several other practical programmes, including education, alleviation of malnutrition, changing behaviour of farmers, businessmen and officials, pollution prevention, and many other complementary action plans must be betrothed in parallel, as we — the Preventive Health, Environmental Protection, and Research Organization (PHERO Foundation) — have proposed and recommended to the Government over the past few years.
In broader terms, the ability to prevent CKDmfo depends on the provision of affordable and accessible clean water, educating the public and healthcare workers on environmental protection and healthy habits, reintroduction of agricultural extension services, responsible and less use of all agrochemicals and other chemicals, early diagnosis of the disease, cost-effective interventions, and improving nutrition.
What would not prevent
the CKDmfo?
Establishing new renal hospitals, expanding dialysis centres and renal transplant centres, while escalating costs, would not reduce the occurrence of CKDmfo. While it would assist thousands of people, mostly farmers, who are pretentious with severe CKDmfo, these would further escalate morbidities and enhance the economic burden of the country.
Similarly, the provision of ‘promised monetary compensation’ of Rs. 3,000 per CKDmfo affected person (conservative estimates of more than 100,000 affected people) will not have any impact on efforts to prevent the disease. Instead, if this money – Rs. 3 billion — is rightly and wisely directed toward prevention programmes, it would be more than adequate to eradicate the disease from Sri Lanka. So, the availability of funds is not the issue, but the lack of priority, direction, focus and the guidance is.
Outcomes of preventative efforts
Once an effective preventative programme is in place, there will be a marked reduction of the number of patients with CKDmfo. Consequently, the number of patients requiring dialysis would decrease markedly, as would the demand for renal dialysis units. Therefore, establishing new renal hospitals and dialysis centres would in fact become unnecessary. Without real efforts and spending on preventing the disease, establishing renal hospital(s) [whether it is via local funds, Chinese or Japanese aid], is the wrong way forward. Moreover, none of these have any impact on preventing persons newly acquiring this deadly disease or preventing premature deaths.
What needs to be done?
The lack of preventative actions would make the legislature ethically and morally responsible and also fiduciary liable for the premature deaths of farmers. What the president and the government should be seeking from foreign donor countries such as China and Japan, is not ‘new hospitals’ but funds to prevent and eradicate this deadly disease.
To eradicate the disease, it is critical to initiate a new “CKD-Eradication Authority” or recognise, authorise and fund credible and highly capable organsations like, Preventive Health, Environmental Protection and Research Organization (PHEPRO) Foundation. One needs to emphasise that measures needed to eradicate this disease are straightforward, yet no proper action has been taken to date.
The PHEPRO has the right technology, resource people, and know-how to eradicate the disease. What’s delaying is the lack of direction and support from the governmental, and to identify and deliver adequate funds to implement this broader project, across the NCP and all other CKDmfo affected regions in the country. In this regard, instead of repeating the mistake of having Task Forces, we hope that the President will create an independent CKD-Eradication Authority [CKD-EA], and empower and adequately finance it do whatever necessary to eradicate this deadly disease from the country.
Lack of funding is not an issue for the government
The comprehensive programme that was put forward by the PHEPRO foundation to the President and the Government, if implemented in full, will eradicate this fatal disease from Sri Lanka within 12 years. Spending 300 million rupees a year for five years that is necessary to eradicate the disease will save more than Rs. 1.7 billion a year savings for the state (i.e., healthcare costs, improved productivity, and opportunity costs).
Another way to look at the necessary funds is the Rs. 300 million to be spent for eradicating the CKDmfo, is less than 6% of the annual gross savings for the government from 10% reduction of fertiliser subsidy! Savings from the “opportunity costs” alone is more than enough to eradicate the disease from the country. Therefore, money is not the issue in initiating preventive programmes leading to the eradication of CKDmfo. However, currently the lack of political will, direction, and priority given to prevention and the spread of the disease and premature deaths of farmers is the main stumbling block. Prevention is the only way forward and thus far it has been grossly neglected.
(The writer is a Professor of Medicine, Endocrinology & Nutrition)