Prof. Sunil J Wimalawansa, MD, PhD, MBA, DSc

ශ්‍රී  ලංකාවාසී ප්‍රබුද්ධ වෘත්තිකභවතුන් වෙත‍ය,

රජරට පවත්නා වකුගඩු රෝගය වලක්වාලීමේ සහ මුලිනුපුටා දැමීමේ ක්‍රියා මාර්ගය – ඉදිරි දැක්ම:

විශේෂයෙන් උතුරුමැද පළාතේ වකුගඩු රෝගීන්ගේ සංඛාව සීග්‍රයෙන් වැඩිවන අතර එමගින් කෘෂි සමාජයේ ජන ජීවිතය විනාශ වීමේ ප්‍රවනතාවයක් උද්ගත වී ඇති බව ප්‍රකට කරැණකි.

එම අන්තරාදායක තත්ත්වය සපුරාම අවසන් කිරීමට නන්වැදෑරුම් ප්‍රායෝගික වැඩපිළිවෙලක් ක්‍රියාත්මක කළ යුතුව ඇති බව ඔබතුමන්ලාද පිළිගන්නවා ඇත.   තිරසාර විසදුමක අරඹයා යන මෙම වැඩපිළිවෙළ ‍පහතින් සංක්ෂිප්තව ඔබගේ අවධානය සඳහා ඉදිරිපත් කරමු.

හේතු සාධක කිහිපයක් පදනම් කර ගනිමින්, වකුගඩු රෝගය උතුරුමැද පළාතේ ආරම්භ වූයේ 1990 දශකයේදීය.   මරණ සංඛ්‍යාව  දස ගුණයකින් වර්ධනය වෙම්න් , දැන් එම රෝගය උතුරුමැද පළාතේ පමණක් නොව ඉන් පිටතද අතිශයිනන්ම අනතුරුදායක මට්ටමකින් ව්‍යාප්ත වෙමින් ඇති බව දක්නට ලැබේ.  මෙම තත්ත්වය මැනවින් අධයනය කළ වත්තීයවේදීන් කණ්‍ඩායමක් විසින් පිළියල කරනු ලැබූ සංක්ෂිප්ත යෝජනාවලියක්  මෙයට අමුණා ඇත.

අප මෙහිලා යෝජනා කරන ක්‍රියාමාර්ගය අනුගමනය කළහොත් වකුගඩු රෝගය නිවාරණය කළ හැකිවා පමණක් නොව, වසර 12-15 ක් ඇතුලතදී රෝගය සපුරාම ශ්‍රී ලංකාවෙන් බැහැර කිරීමට හැකි වනු ඇත.  මෙම කරුණු ඉදිරිපත් කරනු ලබන්නේ ශ්‍රී ලංකා‍‍වේ පමණක් නොව වෙනත් රටවලද වසර 18 තිස්සේ එම විශය අධ්‍යනය කිරීමෙන් අප පදනමෙන් ලබාගත් තාක්ෂණය අත්දැකීම් පාදක කර ගෙනය.

රෝගයට ගොදුරුව පවත්නා ප්‍රදේශ තුල පිරිසිදු පානීය ජලය සහ වෙනත් විවිධ පහසුකම් සැපයීමට අතිරේක වශයෙන් අප ගේ පදනම සහ අනිකෘත් පදනම් මගින්, සම්මන්ත්‍රන සහ වැඩමුළු රාශයක් පවත්වා ඇත.  එපමණක් නොව, රෝගීන් සහ පොදු ජනතාව සමඟද සාකච්චා රාශයක් කර ඇත.

වකුගඩු බෙහෙවින්ම හානි වූ පසුව ඒ සඳහා ප්‍රතිකර්මයක් නැත. එබැවින් වඩාත් යෝග්‍ය විකල්පය වන්නේ රෝග නිවාරණය බව සැළකිය යුතුය.  දැනට සිදුවන අන්දමින් රෝගය වැළ‍‍දෙන තෙක් සිට, ප්‍රමාද වී පිළියම් යොදනවාට වඩා, නිවාරණය සඳහා කාලීනව ක්‍රියා කිරීම වාත් සාර්ථක ඵලදායී එකකි. එය වියදම් අඩු එකම විකල්පයද වන්නේය.

මෙම රෝගය හේතුකොටගෙන වාර්ෂිකව මියයන සංඛයාව 5,000 පමණ වන්නේය.  එයට අමතරව මිලියන 3.0 ක පමණ සංඛ්‍යාවක් දැනට රෝගය වැළඳීමේ අභියෝගයට මුහුණපා සිටිත්.  එබැවින් එළඔ ඇත්තේ එහි අතිශයින්ම අන්තරායකාරී ඉසව්වකටය.  තවමත් මෙම මරණ සංඛ්‍යාව වළක්වා වැඩිවන රෝගින් සංඛ්‍යාව අවම කර, කාලයාගේ ඇවෑමෙන් රුධිර කාන්දුකරණයද (Dialysis) අවම කිරීමටද තවමත් ප්‍රමාද නැත.

මෙවන් විකල්ප ක්‍රියාමාර්ග මැනවින් අධ්‍යනය කර ස්වකීය නිගමනයන් ඇසුරෙන්, ගැටළුව විසදනු සදහා ඇති වෙනත් ක්‍රියාමාර්ග පිළිබද සරලවූත්, ප්‍රායෝගික වූත් උපාය මාර්ග මෙම  පදනම මගින් යෝජනා කෙරින.  රෝගය  වැළදීමේ ශඛ්‍යතාව ඇති ජනයා සඳහා උසස් ප්‍රමිතීයෙන් යුත් පානීය ජලය සැපයීම මෙහිලා ප්‍රධාන විසදිය යුතු අවශ්‍යතාව වන්නේය.

පිරිසිදු ප්‍රජාව සඳහා සැපයීමේදී  රිවර්ස් ඔස්මෝසිස් (Baahira Arssuthiya) තාක්ෂණය සහ අනිකුත් තාක්ෂණ (උ.දා.: වැසි ජලය-rain water harvesting) මෙහිලා නිර්දේශ කරනු ලැබේ.  එම ක්‍රියාදාමය සැකසුම් කිරී‍මේදී ජලයෙහි ස්වභාවය, භෞමික පාරිසරික සාධක, සමාජීය හා ආර්ථික ව්‍යුහය, සහ දැනුමත් කිරීමේ අධ්‍යාපනික වැඩ සටහනක්ද සැලකිල්ලට ගත යුතුය.

මෙම පදනම මඟින් යෝජිත ක්‍රමවේදය අනුව, රජය විසින් ක්‍රියාදාමය සැකසුම් කළහොත්, වසර 12 ක් සහ 15 ක් ඇතුලත අසාධ්‍ය වකුගඩු උවදුර ශ්‍රී ලංකාවෙන් තුරන් කළ හැකිය (වැඩි විස්තර සදහා අංක 01 ඇමුණුම බලන්න).

මෙයට විශ්වාසනීය,

වෛද්‍ය සුන්ල් ජේ. විමලවංස,  MD, PhD, MBA, DSc.

අන්තරාසර්ය විද්‍යාවේදී (endocrine) සහ වෛද්‍ය විද්‍යා අන්ශවල මහාචාර්ය

Presidnet, Wimalawansa Foundation & PHEPRO Foundation

www.linkedin.com/pub/sunil-wimalawansa-md-phd-mba-dsc/16/3b0/5a2/

 

Preventive Health, Environmental Protection, and Research Organization

PHEPRO Foundation

105 Hunupitiya Lake Road, Colombo 2
Tel 011-570-0400; Fax 011-247-2535

_______________________________________________________________________________________

15^th April, 2015

Hon. Maithripala Sirisena                                                                                                                          (updated)

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 that has predominately affected the north central province (NCP) of Sri Lanka continues to claim new patients and destroy the agrarian civilization of Rajarata.  We welcome your pledge to bring an end to this danger and believe that the proposal we present here will assist you in making good on your pledge to the nation to bring about a solution to this epidemic.

The chronic kidney disease of multi-factorial origin (CKDmfo) [also known as CKDu; CKDuo, CKDua, etc.] surfaced in the early 1990s in the NCP.  It currently is spreading within and beyond 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, spearheaded by the president of the PHEPRO Foundation, an international scientist, Professor Sunil Wimalawansa, who has studied CKD in Sri Lanka and other countries for more than 18 years.

CKDmfo is preventable and can be eradicated from Sri Lanka within 12 to 15 years by following the course of action we propose.  In addition to providing various forms of relief and clean water to the affected communities, The Foundation has conducted many seminars and workshops and consulted with professionals, affected people, and the general public before putting forth the proposed solutions.

Once the kidneys are significantly affected, there is no cure for CKDmfo.  Prevention is the best option and much cheaper than providing treatment, including dialysis, after individuals have the disease, which it what is happening now.  CKDmfo kills more than 5,000 per year.  Another 3.0 million across the country are at risk of contracting the disease.  All these deaths and the emergence of patients with newly contracted disease can be prevented and the requirement for dialysis markedly reduced with time.

PHEPRO Foundation has 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 solutions is supplying quality water to all vulnerable people.  The recommended method is the use of reverse osmosis (RO) technology to purify and supply water; with the use of other complementary methods such as rain water collection.  The entire plan must be designed strategically, taking into consideration water quality, geo-physical factors, and social and economic situations, while also providing intensive education programs.

PHEPRO has proposed a strategy that can eliminate the deadly CKDmfo from Sri Lanka within 12 to 15 years (please see Attachment 1 for details).  We envisage that you will review the contents at your earliest convenience.  If you have questions, we are available to answer them.

Yours faithfully,

Dr. Sunil J. Wimalawansa
Professor of Medicine, Endocrinology & Nutrition

President, PHEPRO Foundation
Attachment 1

Summary of the Workshop and Recommendations

Chronic Kidney Disease of Multi-factorial origin, Prevention and Eradication:
The Way Forward

Issue:  Chronic kidney disease of multi-factorial origin (CKDmfo) appeared in the 1990s in the North Central Province (NCP).  It is spreading within and outside the NCP region, and the death toll is doubling every 4 to 5 years.  Although the initial reporting of the disease was within the NCP region, new cases are emerging from other parts of the dry zone.  Most of those affected are male farmers whose living environment has been subjected to drastic modifications in recent years.  These changes include large-scale irrigation development, groundwater contamination, modern agriculture that relies on the use of agrochemicals with consequent overuse of those chemicals, high levels of poverty and malnutrition, abuse of medication and alcohol, and poor access to modern health care and education.  Evidence suggests that many of these factors are acting jointly, which is likely to aggravate the situation and cause the disease (multifactorial aetiology).

Prevalence of CKDmfo: Reportedly, the number of deaths attributable to CKDmfo each year has risen to more than 5,000 (approximately, 14 deaths per day).  Once established, the disease is painful, incurable, and associated with serious personal financial difficulties.  Consequently, approximately, 1 in 14 of the daily deaths is a suicide.  For a number of reasons, the currently available statistics from the Department of Health grossly underestimate disease severity, the disease burden on families and society, and the number of deaths attributed to CKDmfo and thus, misleading to use such for long term planning and allocations of resources.

Cause of the disease: Research carried out by Sri Lankan and international organisations and scientists suggests that the disease is not caused by a single factor but likely is attributable to multiple factors that harm the kidneys (our terminology of CKDmfo reflects the multi-factorial nature of the disease).  A clear, universal understanding of the multi-factorial aspect of the disease would greatly facilitate focussing research and taking concerted action to manage CKDmfo.  Unfounded actions, such as banning agrochemicals in the absence of credible scientific data, will have no impact on reducing the disease burden but likely will increase costs for consumers.  However, we fully support the responsible use of agrochemicals and taking action to reduce their indiscriminate use because of their potential indirect contributions to disease occurrence and environmental pollution.

CKDmfo is a chronic emergency: Because of delay in measures to implement preventative actions, including the provision of quality water to vulnerable populations, the disease has become a chronic emergency” in affected areas and is spreading rapidly into other regions.

We submit that one of the key priorities to preventing the disease is to supply affordable, accessible, clean water to all communities at risk; which is a human right.  Nevertheless, clean water alone will not eradicate the disease because there are many other aspects to address.  Neither the expanding dialysis centres nor building new kidney hospitals will prevent the disease.  Although the treatment of the persons already affected is essential, taking immediate action to prevent healthy people in the NCP from acquiring the disease is even more important.  It is the only way to keep the treatment costs and other societal and economic problems associated with the disease in control and the NCP community intact.

Based on existing scientific evidence and our calculations, we firmly believe that with the detailed program we have proposed to the government, including providing clean water, the incidence can be reduced (prevention of the disease) and the disease eradicated from Sri Lanka within 12 to 15 years.

CKDmfo prevention workshop: In this regard, we recently conducted the workshop Chronic Kidney Disease of Multifactorial Origin; Prevention and Eradication” at the Hector Kobbekaduwa Agrarian Research and Training Institute, organized by the Preventive Health, Environmental Protection, and Research Organization [PHEPRO] Foundation.  Participants included a number of interested individuals representing the civil society, business community including CEOs, university students, and scientists and other professionals.  The participants assessed the existing evidence and knowledge on CKDmfo and discussed the way forward toward launching a program for prevention of CKDmfo and its eventual eradication.

The convener, Professor Sunil Wimalawansa (https://wimalawansa.org/community_projects), has been engaged in CKDmfo prevention and eradication programs for the past 18 years via his charitable programs in the NCP.  He summarized the current knowledge and knowledge gaps that need to be filled to eradicate CKDmfo.  Upon considering all available data and scientific research evidence and the views expressed by local and foreign scientists, the Workshop participants reached consensus on the following:

1. The cause is unknown but likely is attributable to a number of factors working together that are related to recent changes in the environment and human behaviour. The fundamental means of contracting the disease is via contaminated water; multiple interacting nephrotoxic chemicals that originate from natural (e.g., fluoride, climate change, etc.) or modified environments (poverty-driven malnutrition, agrochemicals, medications-NSAIDs, alcohol, etc.) contribute in an additive or synergistic manner.  Thus, instead of the use of CKD of unknown” aetiology (CKDuo), the disease should be called CKD of multi-factorial origin [CKDmfo].
2. CKDmfo is a rapidly expanding, an environmentally induced, acquired, occupational disease.
3. There is no common definition of an affected” individual. The number of those affected has been estimated to be between 40,000 and 180,000 by different agencies and organisations.
4. The current screening and diagnostic criteria and methods used are inappropriate and identify only one-third of those affected. Thus, a tubular-specific, sensitive screening method must be developed.
5. Kidney damage is caused by the consumption of poor quality” water; thus, the provision of affordable, clean water is one of the keys to preventing the disease.
6. Given the high cost of treatment and the opportunity costs (approximately 2.0 billion rupees per year), the negative social and economic impacts on families in the NCP and country, and the impact on the economy, prevention of the disease is not only the way forward but also the most cost-effective solution—much less expensive than merely treating those affected. Eradication of the disease will cost the same as the economy currently loses in one year because of CKDmfo.
7. CKDmfo is preventable (50%) by providing clean water for drinking and cooking. In addition, prevention will require educational and environmental programs and alleviation of poverty and malnutrition. If the disease is identified at an early stage, its progression can be prevented with clean water, improved nutrition, and basic medications.
8. Through concerted actions described in the attached documents, we strongly believe that the disease can be eradicated within 12 to 15 years.

We appreciate your initial actions and desire to take seriously this disease.  There have been several Presidential CKD Task Forces and Working/Monitoring Groups; none has been successful.  This is in part because of a lack of leadership, scientific knowledge, and commitment and conflicts of interests.  Appointing similar government entities will not work.  Instead of the recently appointed yet another Task Force (or other similar governmental organisation), we urge you to establish a CKD Eradication Authority (CKD-EA)” that is independent of ministries and government departments, reporting directly to you.  Focussing resources at one place, leverage understanding of the disease using in-depth science and implementing a practical, cost-effective program to prevent and eradicate the disease from Sri Lanka.

Recommendations for Action Plans:

Continuing to provide the best possible and most cost-effective treatments (including three-shift use of all dialysis machines) to affected individuals and going forward with a multi-disciplinary research program to establish the causal factors of the disease are important, but the following concrete action plans and solutions are recommended for prevention and eradication of CKDmfo via the new CKD-EA or the PHEPRO Foundation:

• A committed program should be launched to provide vulnerable communities with clean water; the program should be coordinated and implemented by the CKD-EA. Once adequate funds are provided to the program, its mission will be completed in 18 months.
• Identify potential threats in vulnerable communities in part based on the quality of water consumed and associated environmental pollution, and generate real-time, geographic information system (GIS)-guided interactive maps across the NCP to identify clusters of patients, deaths attributable to CKDmfo, and contaminated and clean water sources.
• Identify all affected persons (and their locations using GIS mapping) and prioritise treating them according to the disease prevalence and 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.
• Launch an affordable and accessible region-wide, clean water program through the combination of water purification using RO units, rainwater collection systems and other methods, providing safe water for drinking and cooking purposes to all in the region.
• Study the impact of giving clean water” on people and the effect on disease control (statistics).
• Introduce soil testing and promote educational programs to reduce the use of agrochemicals.
• Promote educational programs in schools from grade five onward that have a special initiative to promote nature and environmental protection and environmentally friendly agricultural methods.
• Wage a national education campaign using the media to prevent environmental pollution and protect nature.
• Provide mass media-based education on the prevention of environment pollution and the judicious use of agrochemicals; giving a high priority and be a private–public partnership.

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

For others to know that proper weight has been given to the knowledge gained from much local and international research and that an appropriate way forward has been given due priority, we would like to know the Terms of Reference of the current CKD Task Force you have appointed, including the timelines and objectives set.

We are concerned about the lack of preventive actions during the past decade; this lack of response has led to the premature deaths of thousands of farmers and the destitution of their families.  We urge Your Excellency to replace all existing CKD-related Task Forces and units and establish a novel agency charged with eradication of CKDmfo (CKD Eradication Authority; CKD-EA) that is headed by a credible, senior scientist with the necessary academic qualifications and field experience.

The CKD-EA must have vested powers and the financial capacity to coordinate all actions and aspects to deal with the management of CKDmfo, leading to its eradication 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 immediately provide the necessary finances, as we have proposed to you previously.

The PHEPRO Foundation consists of several charitable organisations and includes independent scientists, medical experts, sociologists, engineers, philanthropists, and social service personnel.  The Foundation is dedicated to eradicating CKDmfo; supporting nurturing, and conducting region-wide coordinated programs to protect the environment; and providing clean water for affected individuals to recover from the disease.

Giving handouts, expanding dialysis centres, or creating new renal hospitals will not prevent the disease, and thus is NOT the key solution to the problem.  In fact, the country may not need renal hospital(s).  For example, if 20% of the funds allocated for ‘one’ renal hospital is adequate for eradication this disease, if spent on preventative programs.  When the disease is prevented using the action plan that we propose, much of the demand and need for renal dialysis will disappear.

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.  Behalf of members of the PHEPRO Foundation and scientists from the CKDmfo, Prevention and Eradication: The Way Forward.

The Solution to the Problem is Directly Solving the Problem.

Yours faithfully,

   Sunil Wimalawansa

Prof. Sunil J Wimalawansa, MD, PhD, MBA, DSc               [Medicine, CKD, Science, Water & Environment]

Prof. Stanley Weeraratne, PhD                              [Agronomics, Environment & Water]

Dr. Nihal Atapattu, PhD                                             [Agriculture & Science]

Eng. Ananda Jayaweera, Eng., MSc.                     [Engineering, Water & Sanitation]