In Sri Lanka, new steps target mysterious kidney disease

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Slideshow: Mystery in the Fields

By Anna Barry-Jester

A woman bathes outside a well in Sandamalgama, Sri Lanka.

Anna Barry-Jester

A woman holds a photograph of her husband and men who worked with him in the sugar cane fields near Chichigalpa, Nicaragua. The man died from chronic kidney disease; four of his sons currently have the disease.

Anna Barry-Jester

A man holds his young sleeping children in La Isla, a community near Chichigalpa, Nicaragua, which has been hit hard by a mysterious epidemic of chronic kidney disease.

Anna Barry-Jester

Children, whose father died from chronic kidney disease, collect leaves to wrap food to sell in their community near Chichigalpa, Nicaragua.

Anna Barry-Jester

Children play in a stream near their home in La Isla, Nicaragua. Workers at the nearby sugar cane plantation have alleged for nearly a decade that pesticides and working conditions are responsible for the epidemic of chronic kidney disease in their area, while researchers have found evidence that chronic dehydration may play a key role.

Anna Barry-Jester

The epidemic in Central America spans six countries along a nearly 700-mile stretch of the Pacific coast. Kidney disease has killed more people in El Salvador and Nicaragua than diabetes, HIV/AIDS and leukemia combined in the last five years.

Anna Barry-Jester

Luis Asavedo, 37, hours before he died from chronic kidney disease in Nicaragua. His wife and 9-month-old sat with him in the final hours.

Anna Barry-Jester

Children and women are reflected in a well in Uddanam, India, an area heavily affected by CKD. In India, the epidemic affects a very particular geographic area along the coast of northern Andhra Pradesh, leading researchers to hypothesize that it may be due to a toxic exposure in the water or soil.

Anna Barry-Jester

 

The mysterious form of chronic kidney disease in India mostly affects farmers in the region, where cashews, rice and coconut are the main crops. However, unlike similar epidemics in Central America and Sri Lanka, researchers from Harvard and Stony Brook Universities have found that men and women are almost equally affected.

Anna Barry-Jester

Laxmi Narayna undergoes dialysis treatment at Seven Hills Hospital in Visakhapatnam, India. The coconut farmer travels hours to and from the city each week for treatment, but according to his doctor, "on dialysis people don't do well. Holding on for a year would be just about it."

Anna Barry-Jester

Laxmi Narayna begins the long journey home from Seven Hills Hospital in Visakhapatnam, where he receives dialysis treatment twice a week, to his village of Gonaputtuga in northern Andhra Pradesh. A state government insurance program pays for his treatment and covers some of the travel costs. The little he currently pays is already a burden for the coconut farmer and his family.

Anna Barry-Jester

A farmer tills his rice paddy in Padaviya, Sri Lanka. A recent government report found that cadmium and arsenic are partly responsible for the CKDu epidemic in North Central Sri Lanka, stating that "prevention of indiscriminate use of fertilizers and certain pesticides which have nephrotoxic properties can help to protect the kidney."

Anna Barry-Jester

Wimal Rajarathna receives dialysis treatment at Anuradhapura General Hospital.

Anna Barry-Jester

The Sri Lankan government is vowing to impose tighter controls on pesticides and fertilizers amid growing concern the chemicals are helping fuel a mysterious epidemic of chronic kidney disease devastating its north central region.

In September, in Mystery in the Fields, the Center for Public Integrity explored how a rare form of chronic kidney disease is killing agricultural workers in Sri Lanka, India and Central America. Scientists in each region are struggling to identify the cause of these parallel epidemics, which have led to tens of thousands of deaths worldwide and are suspected to be linked to a toxic exposure.

In a November 2012 speech laying out a national budget proposal, Sri Lankan President Mahinda Rajapaksa pledged to take action to crack down on contaminated agrochemicals.

“There is a theory that pesticides and chemical fertilizer contribute to increase non-communicable diseases,” Rajapaksa said, referring in oblique terms to the politically controversial kidney epidemic. “Therefore, regulations will be formulated to require suppliers and distributors of all agrochemicals to comply with quality standards.”

A committee of government ministers is meeting with scientific experts and interest groups and will submit a report to the cabinet with recommendations for the regulations, said Sri Lanka’s Registrar of Pesticides, Dr. Anura Wijesekera. 

Wijesekara, whose office oversees imports and permitting of agrochemicals, said Sri Lanka had already taken a significant step earlier this year: establishing limits of detection for nine toxins including cadmium and arsenic. Pesticides and fertilizers containing more than the permitted amounts of these chemicals are prohibited from distribution.

The country has not always moved swiftly to restrict pesticides.

Following years of official research, the Sri Lankan health ministry and World Health Organization declared in June that low level exposures to the heavy metals cadmium and arsenic were “causative factors” for the ailment – which they have named CKDu, chronic kidney disease of unknown etiology. Despite prior warnings from the WHO to reduce farmers’ exposure to agrochemicals, the Sri Lankan government in 2011 lifted a temporary ban on pesticides it had found to be contaminated with small amounts of arsenic, the Center reported.

Wijesekara said he lifted the ban because the levels of arsenic contained in the pesticides were too low to pose a threat.

Now, Wijesekara said his office is acting to curb marketing by fertilizer and pesticide producers, which he said encouraged farmers to use excessive amounts of agrochemicals. “They had been trying to advertise pesticides as fast-moving consumer goods,” Wijesekara said of the pesticide industry.

Yet even as it tightens controls, the Sri Lankan government has not released the scientific reports it says provide the basis for its policies.

In June, when the WHO and Sri Lanka’s health ministry cited cadmium and arsenic exposure as a possible cause for CKDu, they did not publicly release their supporting evidence. WHO officials said a technical report detailing the lab results  would be released in late September. That deadline shifted to late October, and was pushed back again as the report was submitted to the Sri Lankan health ministry for review. On December 20, Sri Lanka’s Director General of Health Services, Dr. Palitha Mahipala, told a CPI reporter he would share the technical report, but the WHO then indicated it would not be ready until mid-January.

Some experts question whether the government truly has evidence to back up its assertions. Wijesekara said he attended closed-door sessions earlier this year in which the WHO presented its scientific findings to government officials and leading researchers. He said  the WHO indicated the culprit was cadmium rather than arsenic, but did not share detailed evidence linking the exposure to agrochemicals. “I don’t have any scientific evidence to accept that they  cause CKDu,” Wijesekara said.

Protections for kidney recipients

As the official study remains sealed, Sri Lanka is acting to improve treatment for the flood of CKDu patients in its hard-hit northern farmlands. This fall, the government hospital in the city of Anuradhapura, the capital of Sri Lanka’s North Central Province, performed its first kidney transplants, which offer the only chance at long-term survival for patients with advanced cases of the disease.

Among the seven patients receiving transplants in Anuradhapura was 21-year-old Sampath Kumarasinghe – an ailing rice farmer the Center profiled in September. Sampath had his transplant on Sept. 25 and is recovering successfully, said Dr. Rajeewa Dassanayake, the head of the nephrology unit at the Anuradhapura hospital.

Yet his path to a new kidney came after a twist involving a potential donor.

In September, the Center reported that Sampath was expecting a kidney donation from a stranger named W. B. Ajantha, who said he was following the example set by Buddhist monks and donating his kidney for free.

Dr. Dassanayake said the hospital has since discovered that Ajantha had been offering his kidney to various patients – taking small payments and requesting lodging for his family in advance. “He pretends he's going to give his kidney, asks for a couple of hundred rupees," Dassanayake said of Ajantha.

Dassanayake and Sampath said Ajantha had lived with Sampath’s family and relied on them for support for weeks before the operation. Sampath ended up getting his kidney from a cadaver. A few days after the surgery, Ajantha left the area. He could not be reached for comment.

Of late, Dassanayake said, some individuals and groups have emerged seeking to exploit the epidemic. To prevent problems, Dassanayake said his hospital only accepts kidney donations from Buddhist monks and relatives of patients, and prohibits donors from selling kidneys for a fee. He said he has seen people falsely claiming to be brothers in order for one to sell their kidney to the other, and other instances in which money changed hands between family members in exchange for a kidney donation.

"When people don't have a donor they get really frustrated and pluck at straws,” Dassanayake said. “There are various people and organizations who pretend to help people find a kidney as well, but I don't know a single patient who has found a kidney through one of these organizations.”

Anna Barry-Jester contributed to this report.