Features
Eradicating CKDu From Sri Lanka is Straightforward—What is Preventing it?
by Drs. Sunil J. Wimalawansa and Chandra B. Dissanayake
(Prof. of Medicine and Prof. of Geology)
Since identifying chronic kidney disease of unknown etiology (CKDu) in Sri Lanka in the mid-1990s, little progress has been made in aetiology and prevention. Despite the numerous hypotheses and conjectures—with more than 35—none have been thoroughly studied or substantiated as the definitive cause of CKDu.
The development of CKDu necessitates simultaneous exposure to various factors and conditions over an extended period. Hence, it is also called chronic kidney disease of multifactorial origin (CKDmfo). A recent newspaper article suggested that Chinese researchers re-confirmed the lack of association of agrochemicals, heavy metals, or arsenic (common postulated factors) with CKDu, consistent with our and other scientists’ publications over 15 years.
Comparatively, on a per-hectare basis of arable land, New Zealand and numerous other countries employ more than ten-fold the amount of agrochemicals and fertilisers containing heavy metals. Similarly, in Sri Lanka, in hilly country like Nuwara Eliya, and wet zones, farmers extensively utilize inorganic fertilisers, especially phosphates and pesticides—significantly more than in the dry zones. Surprisingly, there is little to no reported incidence of CKDu in these regions.
Research studies on hypothesis-driven causation are needed
The lack of conclusive evidence on CKDu stems from inadequately designed studies that fail to assess causes and test specific hypotheses. No CKDu study has rigorously applied Hill’s criteria for disease causation to distinguish casual association from causation. To address CKDu causes effectively, detailed empirical studies, not just descriptive ones, are essential. [For more details, refer to Hill, A.B., 1965, “The Environment and Disease: Association or Causation?”]
(https://www.ncbi.nlm.nih.gov/pubmed/14283879].
No credible scientific evidence supports the role of any of the mentioned postulated factors in contributing to or causing CKDu. Definitive conclusions necessitate well-conducted, unbiased studies with proper design and sufficient statistical power to thoroughly assess or rule out the potential effects of heavy metals, algal toxins, and agrochemicals on CKDu.
Critical causative criteria for establishing a link between a factor and a disease include the Strength of the association, Consistency, Specificity, Temporality, Biological gradient, Plausibility, Coherence, and Empirical data (Experiments). The presence of the majority of these factors is necessary to attribute causation. However, most studies on CKDu are heterogeneous and descriptive, offering limited value. Therefore, conducting meta-analyses using such data is scientifically unsound and inappropriate, as they will likely yield misleading conclusions.
Because CKDu arises from forming nanocrystals and nanotubes in kidney tubules and tissues, a more fitting designation would be “CKD of crystal-tubular nephropathy” (CKD-CTN). The accompanying figure illustrates critical factors contributing to the CKD-CTN development (from Wimalwansa & Dissanayake, Euro. J. Med. Res., July 2023: https://rdcu.be/dgagf). (See Figure)
Poorly designed studies generated inconclusive data:
Compartmentalized research and poor study designs consistently fail to address research questions and test hypotheses related to CKDu. This lack of adherence to fundamental scientific principles, along with issues in improper sample collection and data integrity, has resulted in skewed and unreliable conclusions, muddling the progress and analyses of CKDu in the country.
Extrapolating such data to the overall status of CKDu in Sri Lanka and other tropical countries shifts attention away from identifying actual causative factors, proper fund allocation, and implementing essential remedies for CKDu prevention. Biased comments by Chinese scientists, such as ‘aristolochic acid,’ while relevant in rural China, are not pertinent to CKDu (CKD-CTN) in the dry zones of Sri Lanka.
Methodological and conceptual failures:
No conclusive evidence supports agrochemicals (glyphosate) or heavy metals causing CKDu. Claims linking slightly elevated magnesium in drinking water to CKDu lack reliability due to sampling and methodological errors. In contrast, over 750 international research articles establish magnesium as a “renal protector” in humans.
Detecting an isolated elevation of magnesium or extremely low levels of glyphosate in inconsistent studies is insufficient to establish even an association, let alone causation. Such findings meet only one of Hill’s Causation criteria. Inferences from random water samples and two rat studies lack reproducibility and conclusiveness. The flawed extrapolation of this data to assert that glyphosate or magnesium causes CKDu has diverted attention and national research funds to unproductive programmes. The crucial factor in drinking water is the “calcium to magnesium” ratio, not individual components alone.
Glyphosate or other chemicals used in intervention experiments, equivalent to body weight on a kg basis, are “astronomically” high—toxic. Such concentrations do not exist in water or soil under normal conditions. Such concentration exists when an individual ingests concentrated glyphosate. Therefore, conclusions from such experiments are misleading. Any toxicity dependent on the “dose and exposure” and real-world scenarios do not match the extreme concentrations used in intervention experiments.
Studies have consistently lacked rigorousness during sample collection, standardized methodology, and the use of controls. They also lack quality control during analyses and testing hypotheses. Methodological errors, such as smaller sample sizes and a lack of control experiments, introduce random- and Type-2 errors into the data. To obtain accurate insights, examining thousands of properly collected water samples across affected regions is crucial, as is comparing them with comparable but non-affected villages within the same region (e.g., subtractive analysis), even within ‘affected’ villages, pockets with good-quality drinking water (e.g., natural springs), thus clusters of unaffected families. Therefore, calling the entire area as CKDu affecting is a misnomer.
The neglect of already published data
Suppose one uses “CKD” as a keyword in the following URL: one can pull over a dozen research articles illustrating that CKDu is triggered by “natural” causes—hard water (Ca2+), excess phosphate in combination with fluoride” and chronic dehydration.
https://www.researchgate.net/profile/Sunil-Wimalawansa/publications
Peasants experiencing chronic dehydration due to daily exposure to hot climates and nightly alcohol intake, along with drinking water high in Calcium, Carbonate/ Phosphates, and Fluoride ions, etc., create a “conducive internal environment” for the formation of calcium phosphate (CaPO4) crystals within renal tissue. Additionally, hard water chelates glyphosate, eliminating its potential toxicity, if any, whereas fluoride has the opposite effect.
Chronic exposure to excess calcium, carbonate/phosphate (and other anions), and fluoride through the ingestion of hard water over a decade is necessary to induce CKD-CTN. Such extended exposure maintains the mentioned higher ionic concentrations in renal tissues. Chronic dehydration leads to consistently concentrated urine, enabling the precipitation of hydroxy- and oxalate-apatite nano-minerals in the kidneys. This process occurs with or without fluoride, but fluoride stabilizes these nano-mineral crystals, forming fluorapatite resistant to degradation, allowing crystals to grow. Fluorapatite nanocrystals are implicated in causing CKD-CTN, causing fatal renal failure. The detailed mechanism is illustrated in the following article: https://www.mdpi.com/2076-3298/7/1/2
The way to prevent and eradicate CKDu:
Consuming potable water and avoiding prolonged dehydration can prevent persistent dehydration-associated CKD-CTN. This concept offers highly cost-effective and straightforward solutions to safeguard peasants, particularly farm laborers. This eliminates silent, deadly disease, without needing expensive medications, interventions, or the construction of dialysis centers and hospitals, which is especially crucial in financially strained circumstances.
Research, including ours, has shown that increasing daily access to clean water significantly reduces CKD-CTN incidence and associated morbidities and premature deaths. Unfortunately, once the disease progresses beyond CKD stage IIIB, the damage becomes irreversible. It leads to hardening and shrinkage of the kidney due to fibrosis—resulting in permanent damage.
The following two published articles provide a detailed methodology and cost-benefit analysis of ways to eradicate CKDu from Sri Lanka:—CKD-CTN.Public health interventions for chronic diseases: cost-benefit modelizations for eradicating chronic kidney disease of multifactorial origin (CKDmfo/ CKDu) from tropical countries. Heliyon 2019;5(10):e02309. DOI: 10.1016/j.heliyon.2019.e02309.And Strategic framework for managing non-communicable diseases: Preventing chronic kidney disease of multifactorial origin (CKDmfo/CKDu) as an Example. Chronic Dis Int 2015;2(2 (1018)):1-9 (https://austinpublishinggroup.com/chronic-diseases/fulltext/chronicdiseases-v2-id1018.php).
The direct approaches outlined in the above articles offer ways to mitigate and eradicate CKDu/CKD-CTN in Sri Lanka and other affected countries. Unfortunately, there has been a lack of political will to address the issue. For some, it has become an unscrupulous business. The mentioned scientific papers provide details on how implementing a multi-pronged approach can prevent CKD-CTN, reduce premature deaths, and minimize the socio-economic impact on affected families. For more information. More information in:
Environmental health and preventive medicine 2014;19(6):375-394. DOI: 10.1007/s12199-014-0395-5 (https://pubmed.ncbi.nlm.nih.gov/25239006/).
Critical elements need to eradicate CKD-CTN from Sri Lanka
It is essential to systematically address peasants’ lifestyles and dietary habits, improve micro-nutrition, protect their renal and general health, and mitigate CKD-CTN. In addition to providing potable water, other interventions are also necessary to overcome this forgotten killer. Adhering to such would save the lives of people in CKD-CTN-affected tropical countries. They consume insufficient water due to the unpleasant taste of naturally contaminated hard water. Just because peasants do not have a voice is not an excuse to neglect them by the politicians and the government.
The key to eradicating CKD-CTN is prevention through education, lifestyle changes, and increased consumption of clean water—not in treating renal disease or expanding dialysis centers, hospitals, or transplantation services. To effectively prevent CKD-CTN, providing safe and affordable clean water in the affected and adjacent regions in the entire dry zone is essential rather than solely emphasizing aggressive treatment of end-stage renal diseases.
Historical evidence indicates that ancient Sri Lankan Kingdoms, like Anuradhapura, Polonnaruwa, Dambadeniys, Sigiriya, and Yapahuwa, were relocated, primarily within the dry zonal regions, now affected by CKD-CTN. The reasons for these relocations, whether protecting from invading armies, severe malarial epidemics, or deaths due to CKD-CTN, remain uncertain. Proposals to move the entire North Central Province (NCP) population elsewhere or replace the topsoil in the region are deemed impractical and absurd.
The current approach will continue to fail
The current strategy of expanding renal clinics, dialysis and transplantation services, coupled with reliance on aid from other countries, is an ineffective approach that falls short of “preventing and eradicating” CKD-CTN in Sri Lanka. This method is like holding a tail to tame a tiger. Even if the rates of deaths have somewhat slowed, it is likely because many of the most vulnerable individuals are already deceased. The focus should shift towards protecting the younger generation and families. Unfortunately, CKDu has become a business venture for many, akin to exploitation during the LTTE war.
In addressing CKD-CTN, vision, political will, and prioritization of programs that cost less than a few months of healthcare expenses for maintaining affected individuals and families are lacking. Sri Lanka possesses the necessary technology, know-how, and essential resources to implement a program for eradication without requiring international expertise. However, inherent conflicts of interest hinder the implementation of the right path and impede progress.
Our latest contribution on the subject [Title: Nanocrystal-induced Chronic Tubular-nephropathy in Tropical Countries: Diagnosis, Mitigation, and Eradication] published on July 2023 in a Nature Journal (EJMR)—PDF of the article available from the following links: https://rdcu.be/dgagf
https://doi.org/10.1186/s40001-023-01162-y
Features
‘Lord Edgware Dies’
It has been some time since I read an Agatha Christie, the plot of which I cannot remember. So, I was delighted to find on the shelves of a friend Lord Edgware Dies, which I had a vague memory of, but no certainty about who had done it.
When I read it, I found that my memory of who was probably the killer was correct, but I could not be certain and the red herrings Christie threw in were so diverting that until almost the very end I wondered if I had been wrong.
The plot is very simple. Jane Wilkinson, who is married to Lord Edgware, tells him that she is desperate for a divorce since she is in love with a very proper Anglo-Catholic peer, Lord Melton, but Edgware refuses to divorce her. She asks Poirot to talk to him, which he does, and is surprised to find that Edgware has told Jane he is prepared to give her a divorce. This was, after he had categorically refused, through a letter, which Jane said she had not received.
That night Edgware is murdered, after Jane had been to see him, or so the butler said, and also Edgware’s secretary. But Jane had been that evening at a grand dinner many miles away, where a dozen fellow guests could swear to her presence.
There was a solution however to the mystery of two Jane Wilkinsons, namely a skilful impersonator called Carlotta Adams who, in the opening chapter had impersonated Jane Wilkinson, who had also been at the performance. But when Poirot goes to see her, he finds that she had been found dead on the morning after Edgware had been killed, of an overdose. And in her bag was a gold case, with a strange inscription, that contained the drug, along with a pair of pince-nez.
Her maid said she had written a letter to her sister in America and posted it the previous night. Poirot asks Inspector Japp to get the letter, and a transcript is received from America, and in it the name of Edgware’s nephew Ronald Marsh is mentioned; he had taken Carlotta to dinner after her performance, with which the book opens, and had then set her a challenge. Japp arrests Marsh, but Poirot is not happy and asks for the original of the letter, which the sister sends him. That shows that a page is missing, and the tear is obvious, though that raises the question as to why it had not simply been cut.
Matters are further complicated by the fact that Marsh had gone in a taxi to the Edgware house, along with Edgware’s daughter Geraldine, in the interval of an opera which had previously seemed to provide them with cast iron alibis. Geraldine had gone in to fetch her pearls so that Marsh could raise money he needed, and thus had an opportunity to kill Edgware, as did Marsh, for the driver said he had got out of the taxi while waiting and gone into the house.
Marsh explained why he had gone to the house on the night of the murder as having followed Bryan Martin, an American actor, who had been in love with Jane, whom he saw go into the house with a key. But there was no one visible when he entered, and Geraldine almost immediately came down and they left together. And Martin too has become an object of suspicion to Poirot, for he had been to see him before the murders were discovered with a story of being followed by a man with a gold tooth – a story Poirot immediately realized was false when he was asked how old the man was, and was told he was young, for young people did not have gold teeth.
A heap of French money Edgware had got for a trip to Paris was missing, but since Marsh had no need for it after his cousin’s offer of help, Poirot deduces that it must have been taken by the butler, who has disappeared. Christie has stressed that he is astonishingly handsome, unusual in a butler, and Poirot notes a resemblance to Martin, so he thinks the mysterious man going into the house must have been him.
Incidentally, later Poirot assumes that Edgware’s change of mind was because he was involved in some scandal, and I believe Christie intends us to see the cause of this in his handsome butler, though this is not specified.
Meanwhile, Poirot has asked Japp to find out the provenance of the case found in Carlotta’s handbag, and it turns out to have been made in Paris, specially commissioned, and collected by a woman with pince-nez.
But then another murder occurs—that of another guest at the grand dinner, which provided Jane with her alibi. The victim is an actor who had been bemused when Jane, at a lunch, thought the Judgment of Paris referred to the city. He told Hastings he wanted to see Poirot, but was killed before he could get to the appointment. Poirot had rushed there when told about his request, but it was too late.
Meanwhile, Poirot has tried out the pince-nez on Edgware’s secretary, but she could not see through these. It was only a chance remark heard outside the theatre that led him to try them out on Wilkinson’s maid Ellis, a spare pair that had been appropriated for the night of the murders.
Poirot then lays things out, having summoned Martin and told him that he probably suppressed Edgware’s letter, as he had been dropped by then and he did not want Jane to marry another. But after teasing Martin, Poirot says that Jane was in fact the murderer, and she got Carlotta to impersonate her at the dinner while she went to the house and killed her husband. After meeting Carlotta later and checking with her through a call that she had
not been rumbled, Jane had gone ahead with the murder – she put veronal into her drink and the case with veronal into the handbag. She forgot to take out the pince-nez she had used earlier to imitate an American. Carlotta had registered as the American in a hotel and Jane had gone to see her, and there they exchanged identities. After seen the letter, she made use of it by tearing off the page that referred to her, and the S of She, so that the person who had challenged Carlotta to impersonate her seemed to be a man.
There is a coda in which Jane, condemned to death, writes to Hastings, still full of pride at her ingenuity hoping she will be remembered.
Features
Desilt reservoirs, learn from our ancient irrigation systems
by Prof. O. A. Ileperuma
Silting of reservoirs is a major problem today affecting our hydropower production and irrigation systems. The main Mahaweli reservoirs are silted to a considerable extent reducing the water holding capacity of them. Due to poor soil management practices, floodwaters deposit large amounts of silt in these reservoirs. When the Polgolla reservoir was fully drained about two years back, one could see mountains of silt in the lower reaches of the reservoir. A rough estimate is that 50% of the total capacity of these reservoirs has been lost to siltation. This is a serious issue which affects not only power and agriculture but also flood control.
Our ancient irrigation systems ensured that desilting of reservoirs took place under royal decree where all users of the reservoirs were ordered to carry out desilting of reservoirs during the dry season. The clay thus collected was used in making bricks for the construction of great stupas which dot the landscape of our ancient kingdoms. This ensured that the reservoirs had their full capacity filled with water for the next cultivating season. Our ancient kings were clever enough not to construct reservoirs by blocking main rivers such as the Mahaweli. A classic example is the Minipe left canal where they tapped only the surface water of Mahaweli. Even the bigger tanks such as Nuwara Wewa and Parakrama Samudraya were fed with minor rivulets. There were also other ingenious features in the cascade irrigation systems built by the ancient kings, such as mud sluice canals and forest reservations between the reservoirs in the cascade system. These reservations helped trap silt and remove excess nutrients, which could otherwise contribute to increasing salinity as water flowed from one reservoir to another.
- Parakrama Samudraya
- Kalawewa
- Kotmale
A classic engineering marvel is the former Yoda Ela, which carries water from Kalawewa to Nuwara Wewa and Tissa Wewa. It is 87 km long although the straight distance between these points is only about 40 km. The gradient of this canal is about 10 cm per km or 6 inches per mile. Yodha Ela functions as a moving reservoir and feeds about 4,600 hectares of paddy lands. It is a winding canal with about 120 smaller reservoirs on its way. It was constructed during the reign of King Dhatusena around 459 AD and later expanded by King Parakramabahu by connecting more reservoirs to the network. Unfortunately, during the Mahaweli project our modern-day engineers constructed a concrete canal replacing the winding path of this Yoda Ela also called Jaya Ganga. This effectively removed the ability of the old Yoda Ela to remove silt and nutrients. The bank of this Ela has wet zone trees such as jak and areca nut growing well. They take up the nutrients from the flowing stream making the water suitable for irrigation later.
Ancient Mesopotamian civilisations depended on dams constructed along the two main rivers, Euphrates and Tigris. After continuous irrigation of their fields over several thousand years, salinity of the irrigated lands increased making them unsuitable for agriculture. People died due to famine and this clearly illustrates the danger of blocking main rivers for agriculture. There is scientific evidence that the salinity of paddy soils in the Mahaweli C area is increasing.
We saw the devastation caused by Cyclone Ditwah. The sluice gates of the Kotmale Reservoir were opened, and Kandy and Peradeniya were flooded. If the reservoir had had greater storage capacity, couldn’t the opening of the gates have been delayed? This may not be an argument that modern-day engineers would readily accept, and I am not an irrigation expert. These ideas may well be naïve. But most of us tend to think of reservoirs mainly in terms of hydropower generation and irrigation, while their role in flood control receives much less attention. The question therefore deserves serious consideration. Could restoring lost reservoir capacity through desilting help improve our ability to manage extreme rainfall and reduce flood risks?
Desilting our reservoirs should be considered a national priority.
Features
Losing out to Ethiopia
Export diversification – Missing the wood for the trees – Part III
by Gomi Senadhira
In Sri Lanka, the word “Ethiopia” is often used as disparaging slang to describe individuals or areas experiencing extreme poverty, starvation, or severe economic hardship. This linguistic habit originated in the 1980s with the Western media coverage of the devastating Ethiopian famine of 1983-85. That media coverage shocked the world but also left an outdated and offensive global stereotype that the country is permanently starving. Much has changed since then. By now, with an annual growth rate of around 9%, it is the fastest-growing economy in sub-Saharan Africa. Ethiopia has also emerged as a highly competitive exporter and is challenging not only its competitors in the region but also countries like Sri Lanka. This article is on how Sri Lanka has lost ground to Ethiopia (and a few other countries) in the GCC markets for agricultural and floricultural products.
Sri Lanka – A Pioneer in the Agriculture and Floricultural Market in the GCC
As discussed in Part II of this article, by the mid-1980s Sri Lanka had established a strong foothold in the GCC’s fruit, vegetable, and floricultural market. Geographical proximity and well-established shipping and air links gave Sri Lanka a strong comparative advantage over Southeast Asian and African nations. Thailand, Vietnam, and Kenya were not even in the market. At that time, Ethiopia was experiencing (as BBC news reports described) “a biblical famine”.
The market was not very large, but it was lucrative and growing. Trade Minister Lalith Athulathmudali as well as the Chairman of the Export Development Board, Victor Santiapillai, who visited Kuwait (and the GCC countries), recognised the market potential for these products and encouraged us to continue with our work. The minister was particularly keen to further develop links between the market for these products, exporters, and his Export Production Villages (EPVs). So, it was becoming a successful case not only for export diversification but also for transferring gains from exports directly to rural households.
From Trailblazer to Tailender
As a result, even by the beginning of this century Sri Lanka had a larger market share than most of its competitors from Asia or Africa. But since then, our competitiveness has weakened significantly. The tables below provide a comparative snapshot of Sri Lanka’s performance vis-à-vis Thailand, Vietnam, Kenya and Ethiopia in the GCC market for vegetables, fruits and floricultural products. As illustrated therein, in 2001 Sri Lanka was ahead of Thailand, Kenya and Ethiopia in this small but rapidly growing market. Since then, we have fallen behind Thailand, Kenya and many other countries in that lucrative market. If this trend continues, Sri Lanka will fall behind Ethiopia within the next few years. (See Table 1)
In the GCC market for vegetables (covered in HS chapter 07), Sri Lanka was ahead of most other competitors in 2001. As illustrated in Table 1 , Sri Lanka had failed to develop this market, while Thailand, Kenya, and even Ethiopia had very efficiently increased their market shares. The GCC is a market to which Sri Lanka can supply some vegetables, like cabbages, by sea. It appears Sri Lanka had also failed to exploit this mode of supply.
We can see a similar trend in the market for fruits. Vietnam, Kenya, and Thailand have emerged as major players, while exports from Sri Lanka have staggered on slowly. In this segment, Vietnam has emerged as a leading player during the last twenty years and the GCC imports from Viet Nam have shot up from US$44 thousand in 2001 to US$346 million by 2024. In part one of these articles, I discussed the remarkable increase of jackfruit exports from Vietnam “…just $3 million in 2015 to an impressive $236.8 million in 2023” while most of our jackfruit production rots under the trees. This explains how countries develop their markets, geographically and product-wise. (See Table 2)
Sri Lanka’s performance has been weakest in the market for floricultural products (HS Chapter 06), which groups live trees, cut flowers, and ornamental foliage. When we first entered the market in the 1980s, the market was dominated by the Netherlands, and Kenya and Ethiopia were not even in the market. At that time, we identified the Gulf states as a market where Sri Lanka could have a dominant presence due to geographical proximity. Even in 2001, Sri Lanka was ahead of Kenya, Ethiopia, and Thailand. But by now, Kenya has emerged as the dominant supplier. Ethiopia is also expanding its market share and is the third-largest exporter. (See Table 3)
Missing the Wood for the Trees
In the mid-1980s, Sri Lanka first established its foothold in the GCC market. Since then, Thailand, Vietnam, Kenya, and even Ethiopia have moved well ahead of us and have become leading players. Why did we lag behind in our export diversification efforts in general and, more particularly, in the GCC market?
The reasons are very clear. After the initial attempts in the 1980s and early 1990s, Sri Lanka has not been proactively involved in identifying, developing, and promoting new products and markets, or protecting and further developing new markets already established. The focus has simply been on traditional exports: tea, coconut, cinnamon, and garments, while other products were almost ignored. In essence, we have been and continue to focus intensely on a narrow group of products and markets, and we have lost sight of the bigger picture.
(The writer can be reached at senadhiragomi@gmail.com)
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