Dr. Sunil J. Wimalawansa,

Hon. Maithripala Sirisena
The President of the Democratic Socialist Republic of Sri Lanka
President’s Office, Colombo 1

Dear Sir: Chronic Kidney Disease in Rajarata, Prevention and Eradication:- The Way Forward

As Your Excellency is aware the Chronic Kidney Disease (CKD) that has predominately affected the north-central province NCP) of Sri Lanka is continuing to claim new patients and destroy the agrarian civilization in Rajarata. We welcome your pledge to bring an end to this danger and believe that the proposal we present below will assist to make good on your pledge to the nation to bring about a solution to this epidemic.

The Chronic Kidney Disease (CKD) of multi-factorial origin (CKDmfo) [previously known as, CKDu; CKDuo, CKDua, etc.] surfaced in early 1990s in the NCP. It is currently spreading within and outside the NCP region at an alarming rate with the death toll doubling every 4-years. The attached brief proposal was made by a Team of Professionals who have studied CKDmfo. It is spearheaded by the president of the PHEPRO Foundation, Medical Professor and an International Scientist, Professor Sunil Wimalawansa, who has studied the subject in Sri Lanka and other countries with CKD for more than 15 years.

CKDmfo is totally preventable and can be eradicated from Sri Lanka within 12 years, by following the course of action we have proposed. In addition to providing various reliefs and clean water to the affected communities, Foundation has conducted many seminars, workshops, and consulted with the professionals, affected people, and the general public before reaching at the proposed solutions.

Once the kidneys are significantly affected, there is no cure for CKDmfo. Prevention is the best option and much cheaper than let people getting the disease and treating/dialyzing them subsequently, as it is happening now. CKDmfo kills more than 5,000 per year. Another 2.8 million across the country is now at the risk of contracting it. All these deaths, and emergence of new patients can be prevented, and the requirement of dialysis can be markedly reduced with time.

PHEPRO Foundation proposed a simple, practical, low-cost strategy based on the findings of the scientists who studied the options thoroughly and evaluated all possible options for solving the problem. One of the key solution rests upon supplying quality water to all vulnerable people. The recommended method is the use of Reverse Osmosis (RO) technology to purify and supply water. However, it must be designed strategically taking into consideration of water quality, geo-physical factors, social & economic consideration, together with an intensive education programs.

PHEPRO is proposing a strategy that can ensure elimination of the CKDmfo from SL within 12 years (please see the attachment 1 for more details). We would greatly appreciate an opportunity to meet you to explain the project further.

Your faithfully,
Dr. Sunil J. Wimalawansa, MD, PhD, MBA, DSc. Professor of Medicine, Endocrinology & Nutrition
President, PHEPRO Foundation

Attachment – 1

Summary of the Workshop and Recommendations Chronic Kidney Disease of Multifactor origin, Prevention and Eradication – The Way Forward Issue:

The Chronic Kidney Disease (CKD) of multi-factorial origin (CKDmfo) appeared in 1990s in the North Central Province (NCP). It is spreading within and outside the NCP region and the death toll is doubling every 4-years. Although, the initial reporting of the disease was within the NCP region, new cases are emerging from other parts of the dry zone. Majority of the affected constituents are male farmers whose living environment has been subjected with drastic modification in recent years. These includes, new irrigation development, ground water contaminations, modern agriculture relying on agrochemicals and the over use of agrochemicals, high levels of poverty and malnutrition, and poor access to modern healthcare and education. Evidence suggest that many of these factors acting jointly, is likely to aggravate the situation and causing the disease.

Prevalence of the CKDmfo: Reportedly, the total deaths per year due to disease have risen to more than 5,000 per year (i.e., 14 deaths per day). Approximately, one out of these 14 deaths is suicides, due to its incurability and the disease-associated financial difficulties. The currently available statistics grossly underestimate its severity, the disease burden on families and the society, and the number of deaths attributed to CKDmfo.

Cause of the disease: Research carried out by Sri Lankan and international organisations and scientists suggest that the disease is not caused by a single factor, but by multiple factors affecting the kidneys. Thus, the disease should be identified as CKD of multi-factor origin [CKDmfo]. This understanding would greatly facilitate focussing research and taking concerted action to manage it. Unfounded actions such as banning agrochemicals without having credible scientific data will have no impact in reducing the disease burden. However we fully support advocating responsible use of agrochemicals and taking actions to reduce indiscriminate use of agrochemicals due to their potential contributions to disease occurrence an environment pollution.

CKDmfo is a chronic emergency: Due to delay in actions to implement preventative actions, including provision of quality water to vulnerable populations, the disease has now become a chronic emergency” in affected areas. Consequently, the disease is spreading into other regions at an unmanageable proportion.
We submit to you that the disease can only be prevented by supplying communities at risk with affordable and accessible, safe, clean water. Neither the expanding dialysis centres nor having new kidney hospitals would prevent the disease. While the treatment of the persons already affected is essential, taking immediate action to prevent new patients is even more important, and is the only means to keep the treatments costs and all other societal and economic problems associated with the disease in control.

Based on existing scientific evidence and our calculation, we firmly believe that the detailed program that we proposed to the government, including providing clean water to vulnerable populations, the incidence of new patients can be prevented and the disease can be eradicated from Sri Lanka within 12 years. CKDmfo-prevention workshop: In this regards, the most recent Workshop we conducted on Chronic Kidney Disease of Multifactor origin, Prevention and Eradication,” was held at the Hector Kobbekaduwa Agrarian Research and Training Institute on the 11 April, organized by the Preventive Health, Environmental Protection, and Research Organization [PHEPRO] Foundation. Participants includes a number of interested individuals representing the Civil Society, Business community, CEOs, University Students, and Scientists and other Professionals. The participants assessed the existing evidence and knowledge on the CKDmfo and discussed the way forward towards launching a program for prevention of CKDmfo and eventual eradication of its occurrence.

The Convener, Professor. Sunil Wimalawansa (https://wimalawansa.org/community_projects) who has engaged on CKDmfo prevention and eradication program for the past 16-years via his charitable programs in the NCP, was the key resource person; he made an in-depth presentation. He summarized the existing evidence on the occurrence of CKDmfo. Upon considering and analysis of the evidence available to date from all research studies published and views expressed by local and foreign scientists, the Workshop participants reached consensus that there is strong evidence that:

a. The cause is unknown, but is likely due to a number of factors working together relating to the changes-associated with the physical environment that affected people are live in. Water soluble toxic compounds and chemicals that originate from natural or modified environment are conveyed by water. Thus, instead of the use of CKD of ‘unknown’ aetiology or CKDuo, the disease should be described as CKD of multi-factor origin [CKDmfo].

b. Modified environment seems to be the key reason for the occurrence and rapid increase of the disease.

c. There is no common definition of an ‘affected’ individual. Numbers of those who are affected has been estimated between 40,000 and 180,000 by different agencies and organisations.

d. The current screening and diagnostic criteria and methods used are inferior and only identify a third of those who are affected. Therefore, tubular-specific, sensitive screening method must be developed.

e. Kidney damage is due to the consumption of poor quality” water; contaminated water is the common factor precipitating the disease; thus, provision of clean water is one of the key to prevent the disease.

f. Given the high cost of treatment and he opportunity costs (approximately 2.0 billion rupees/year), negative social and economic impacts on the affected population, and potential impacts on the economy, prevention of the disease is not only the way forward, but also most cost-effective solution than dealing [treating] with the affected. It costs only one years of losses” to eradicate this disease.

g. CKDmfo is preventable by providing clean water for drinking & cooking, while carrying out educational and environmental programs in parallel. Individuals at an early stage of the illness (before Stage 3b of the 5 stages of infirmity) could be cured with consumption of clean water and basic renal medication.

h. Through concerted action to provide safe” water to vulnerable populations and by several other means, PHEPRO foundation can totally eradicate the CKDmfo within 12 years.

We appreciate that the understanding of the serious nature, you are initiating a ‘Presidential Task Force’ to coordinate actions relating to the CKDmfo. However to-date, all former CKD-Task Forces have been failed. Therefore, instead creating yet another Task Force, we urged you to establish an independent, CKD-Eradication Authority (CKD-EA),” enabling understanding of the disease and proactive management. Recommendations for Actions Plan: While proceeding with measures to provide the best possible and cost-effective treatment to affected individuals and continuing a multi-disciplinary research program to definitely establish the causal factors, following concrete action plans and solutions are recommended for prevention & eradication of CKDmfo via the new CKD-EA or he PHEPRO Foundation:

 A committed program to be launched to provide the vulnerable communities with clean water that is implemented by the CKD-EA.
 Indexing affected persons and prioritise treating them according to the disease prevalence and the CKD progression pattern. This, together with a region wide real-time surveillance program and multi-disciplinary long-term research programs as proposed by The Foundation, should be the basis for effective planning, management and prevention programs.
 Identify potential threats in vulnerable communities as per the quality of water they consume and associated environmental pollution and generate GIS-guided interactive maps across the region to identify clusters of patients and deaths due to CKDmfo, and contaminated and clean water sources.

Identifying and prioritise, (A) the most vulnerable communities according to the quality of water consumed and the clusters of patients, (B) detailed GIS-based real-time maps identifying patient locations, contaminated and clean water sources.
 Launch an affordable and accessible region-wide clean water program through treating surface water and providing safe water for drinking and cooking purposes to all affected and vulnerable villages.
 Study the impact of consumption of clean water by affected people and the disease control.
 Introduction of soil testing and promote educational programs to reduce the usage of agrochemicals.
 Promote educational programs in schools from grade five onwards to have a special Initiative to promote nature and environmental protection in the NCP
 National educational campaign to prevent environmental pollution and protecting the nature.
 Mass media-based education on prevention of environment pollution from all chemical substances, and judicious and lesser use of agrochemicals as a high priority, jointly with private-public partnerships.

In the light of the above we are keen to understand the Terms of Reference of the existing Task Force, its composition, the timelines and the set milestones. This is important in order to understand appropriate weightage is given based on the knowledge available from many local and international research and an appropriate way forward giving due priority to prevention and eradication is adopted by the Task Force.

Nevertheless, we are very concerned with the lack of attention to preventive actions over the past decade that had led to premature deaths of thousands of farmers and destitution of their families. We urge Your Excellency to replace all existing various CKD-related asks Forces and units, and to establish a new Agency charged with eradication of CKDmfo (CKD-Eradication Authority; CKD-EA) that is headed by a credible, senior scientist with necessary academic qualifications and field experience. The PHEPRO Foundation consists of several charitable organisations, comprising independent scientists, medical experts, sociologists, engineers, philanthropists, and social service personnel. The Foundation is dedicated for eradicating CKDmfo, support, nurture, and conduct region wide coordinated programs to protect the environment, provide clean water for them to recover from the disease, and eradicate it.

The CKD-EA must have vested powers and financial capacity to coordinate all actions and aspects to deal with the management of the disease, leading to eradication of CKDmfo from Sri Lanka. We urge Your Excellency to empower this important Agency to take all actions necessary to eradicate this deadly disease from the country and provide necessary finances with immediate effect, as we proposed to you previously.

Expanding dialysis centres or creating new hospitals are NOT the answer to this problem. In fact, we do not need new CKD or Renal hospital(s). If money is earmarked for such, that should be use for prevention and eradication of this disease. When the disease is prevented using the action plan that we have proposed, the demand and the need for renal dialysis will go down markedly.

We are happy to meet with you in person to discuss the way forward in eradicating CKDmfo from Sri Lanka. We look forward to hearing from you at the earliest convenience.
Yours faithfully,

Behalf of all members of the CKDmfo Prevention and Eradication Workshopthe way forward.”

Sunil Wimalawansa
Prof. Sunil J Wimalawansa, MD, PhD, MBA, DSc [Medicine, CKD, Science, Water & Environment]
Prof. Stanley Weeraratne, PhD [Agriculture, Water, & Environment]
Dr. Nihal Atapattum, PhD [Agriculture & Science]
Eng. Ananda Jayaweera, Eng., MSc. [Engineering, Water & Sanitation]