Executive Summary – -Cost-Effective, Sustainable Global Solution to Alleviate Chronic Kidney Diseases in Sri Lanka by Provision of Clean Water to NCP

Background:

Safe drinking water is a fundamental human right, but more than 2.0 billion people in the world still lack access to safe-clean drinking water and to sanitation; Sri Lanka is no exception. Contaminated water and poor sanitation claim more lives than any war or any single disease. Toxic chemicals or organisms affecting health cannot necessarily be seen, tasted, or smelled. Provision of clean water and sanitary facilities can save over 3 million lives globally and about 10,000 in Sri Lanka, annually.

Geographical and other issue pertinent to Sri Lanka:

Chronic Kidney disease (CKD) primarily affects middle-aged farmers. The CKD in Sri Lanka is geographically demarcated, but is spreading to adjoining areas around the North Central Province (NCP) and elsewhere. The agricultural communities are predominantly affected; of which more than 90% live in rural areas with little access to medical facilities. Currently, the CKDu-prone areas cover approximately 20,000 km2, and potentially affecting about 2.8 million people. The occurrence of CKD is due to consumption of polluted water/food. Adverse environmental conditions, irrigation methods, and agricultural habits, chemical fertilizer and overuse of toxic agro-chemical play a role in causing this disease; but no causality is demonstrated. CKDu in the NCP is an -environmental- disease.

Causes and incidence of CKDu:

The water in the affected areas is polluted with toxic heavy metals, cadmium, arsenic, and lead, as well as with fluoride, and toxic agro-chemicals and petrochemicals. Although the specific cause for the CKDu is unknown, it is of multi-factorial origin, and is due to a combination of chemicals & toxins prevalent in this area. The exact incidence or the causes of CKD are unknown, but approximately 100,000 people are currently affected (up to 10 to 15% of people in certain villages) and unfortunately, the incidence continues to increase. An urgent, cost-effective solution is necessary.

The reality:

A centrally purified pipe-borne water supply is the ultimate solution, but this may take another three decades or more to materialize; by then, an estimated 250,000, predominantly middle-aged farmers will be succumbing to CKD. There are no curative measures; prevention is the only way forward. Other than providing centrally purified pipe-borne water or clean water via reverse osmosis (RO) method, there is no other sustainable way of providing clean water to the affected villages; most of which are located in remote areas. However, this must be implemented systematically and scientifically. A variety of commercial filters has been introduced to the area, but none of these seems capable of removing the potential chemicals and toxins efficiently.

Methodologies:

The NC-Region (NCR) desperately needs a cost-effective way to provide safe and clean water for its farming populace. Our analysis indicates that the Reverse Osmosis (RO) is the most cost-effective system than can remove all toxic components from the brackish water in NCP. RO units come as capacity of 200 to 100,000 Liters of purified water, daily. However, not all RO units are the same.

Thus, it is imperative to install the right RO unit in a given village, ideally with a mode of delivery of clean water. Depending on the water quality/turbidity, chemical constituents, turbidity, etc., a prefilter is necessary for the RO units, in most villages. We are currently installing demonstration/pilot units in villages in the Anuradhapura district for interested parties to visit and observe the system.

Education, awareness and pollution prevention campaign:

Village-based and region-wide awareness and educational campaign on (A) consequences of drinking contaminated water, (B) the importance of using safe, and clean treated water, C) water conservations methods, prevention of pollution of water sources and the environment, (D) essential precautions to be taken by farmers when using agrochemicals, (E) utilization of locally available organic substances and compost for cultivation and for pest control, etc. We have an on-going village level educational cum informative campaign on this since 2008; this needs to be intensified.

Issues to consider:

1. Prioritization of villages & identifying optimal location within the village for RO installation of plants.

2. Identification of the right RO units for the right village: as cost-effective, practical, and sustainable way to provide clean water -” via water treatment technology (removing all potential pollutants).

3. Sustainable sources of brackish-water; disposal of contaminated water; method for distribution.

4. Set-up infrastructure for the proper operation and long-term maintenance of RO plants.

5. Widespread Awareness and Education Program on prevention of water pollution.

6. Regular monitoring of water quality as an integral part of the operation and maintenance.

7. Long-term data collation and systematic assessments to eliminate health problems in the region.

8. Capital, operational, maintenance and distribution costs; and cost recovery method.

Cost of instillation RO plants:

On average, RO plants costs about US $8,900 to install (cost varies from $4,000 to $25,000, each unit). An average RO unit provides safe and clean water to approximately 1,500 people (one or a cluster of 2 to 4 villages). We estimate that the entire region requires 380 RO plants, at a cost of US $3.4 million (500 million Sri Lankan Rupees). This is in fact, only bit more than the taxpayers-â„¢ money that spent by t NSF to generate the WHO report (published in May 2013). The maintenance of these plants over the next 15 to 20 years requires an additional US $1.0 million.

Cost-effectiveness:

The number of deaths secondary to CKD in the affected region currently approximates 5,000/year; 13 deaths per day. However, the statistics available are likely underestimated. Thus, each $650 spent on this project will prevent one CKD death per year. Therefore, over the expected life span of 30 years of an RO pant, prevention of one death would only cost US $24.

Another way to look at is the effects of reducing morbidity and mortality within one village following installation on one RO plant. With a rate of 1% current estimated CKD deaths (which is in fact, increasing), each RO plant would reduce ~10 deaths in an affected village, per year. Thus, over a 30-year period, each RO plant will save 300 lives with capital cost of $8,900. There is no medical or other intervention where one could offer a solution to this region that is even close to this costeffectiveness in reducing diseases burden and premature deaths.

Expectation and the Hypothesis: The provision of clean water will significantly prevent the new occurrence of CKD in healthy people. It would also decrease other chronic diseases that are prevalent in the NCR (region). Thus, the clean water consumption prevents and reverses the trend of sicknesses and enables the continuation of productive lives. Moreover, in 2012, health department spent 3.6% of its annual budget (i.e., 350 million rupees) just to treat patients with CKDu; this cost is escalating. Our conservative estimate indicates that the annual cost savings following the implementation of this proposed broader project would be about 500 million rupees per year.

Therefore, a rapid capital cost recovery is achieved after commencing this project.

Current priorities: Commitments and raising funds

A) Regional island-wide educational campaign on prevention of water and environment pollution.

B) Provision of clean, safe potable water using RO systems to CKD-affected villages in Sri Lanka.

C) Broad-based, environmental and sociological research program for CKD-mfo affected areas.

D) Raising funds, and to develop collaborations and partnerships with non-profit and the

private sectors to implement the project and its longer-term maintenance in the region.

Once funds approved, CCPO will professionally install all RO plants within the next 18 to 24 months

to provide clean water to all affected villages in the NCP. In addition to providing clean water,

project will embrace provision of sanitary and toilet facilities. We look forward for meaningful

discussions, undertaking a firm commitment by the government, and a sustainable plan of action.

Sunil Wimalawansa

Professor Sunil Wimalawansa, MD,PhD,MBA,DSc