In the Hot Zone: Chronic Kidney Disease in Sri Lanka
by Ed Kashi
Suffering through nearly three decades of bloody secessionist fighting, Sri Lanka endured unrelenting hardships for the population, environment and economy. Although the civil war ended in May 2009, the nation still faces a fierce battle. Like many other countries around the globe, Sri Lanka is going up against a seemingly undefeatable foe that threatens that nation’s healthcare system and many of it’s rural people — Chronic Kidney Disease of nontraditional causes (CKDnT). Since 2013, I have made seven trips to Nicaragua, El Salvador, India, and, most recently, Sri Lanka to document this global health crisis that has primarily — and devastatingly — impacted poor, rural, farming communities.
For over 2,500 years, Sri Lankans have cultivated rice in the verdant and gentle paddies of this teardrop-shaped island nation. The North Central Province (NCP) is the largest province covering 16% of the country and is comprised of 2 districts, Anuradhapura and Polonnaruwa. It was here that early dreams of agricultural self-sufficiency came into focus as Sri Lankan farmers dotted the land with rice paddies that today produce enough rice to feed the nation’s 20 million people. Besides the predominant rice crops, other products that are cultivated throughout the year include sesame, millet, chilies, peanuts, fruits, vegetables, and dairy products. More than 65% of Anuradhapura’s population depends on farming. Considered the rice bowl or granary of Asia for centuries, Sri Lanka had no historical record of kidney disease of any kind. However, in response to the 1960s Green Revolution, ancient farming practices gave way to modern techniques and chemicals.
Though experts acknowledge the enormous financial, societal, and ecological implications of CKDnT, those involved with efforts to defeat the disease are still debating its multi-factorial causes. Doctors, scientists, researchers, and activists all suspect that exposure to high concentrations of toxins from the heavy usage of agricultural chemicals begun in the 1970s plays a major role. Similar to Central America in both the lush, gorgeous fertile land and the dry, often-blistering heat, Sri Lanka’s NCP epitomizes the disturbingly perfect place for the emerging worldwide health epidemic of CKDnT. Over the past 30 years, the NCP has seen a surge in CKDnT since the condition was first diagnosed in the remote farming community of Padawiya. Known as “Rajarata Kidney Disease” in Sri Lanka, this epidemic has already killed more people in the NCP than the total number of deaths from one of Asia’s longest lasting armed conflicts. This is where I went to document CKDnT and its impact on local agricultural workers.
Fifteen to twenty years after glyphosate (a broad-spectrum systemic herbicide and crop desiccant) was introduced in Sri Lanka, the older men began to experience symptoms of CKDnT. Residues of heavy metals such as cadmium, arsenic, lead and mercury are now present in virtually all water, soil, and human samples. Along with chemical exposure, dehydration, contaminated water from shallow wells and tube wells, modern diet, and extreme working conditions have also been postulated as contributing factors to the disease, which is now showing up increasingly in younger generations.
The fear and associated stigma CKDnT elicits have unfortunately spread beyond the NCP to neighboring provinces. According to the World Health Organization (WHO), more than 15% of the rural population in the NCP and the more southern Uva province are struggling with CKDnT. In Anuradhapura district alone, where people exist amid low socio-economic conditions in the many small villages, approximately 16,500 CKDnT cases are currently devastating families.
While cases of the disease affecting women and children have been reported, the majority of CKDnT victims are male farmers aged 40 to 60. The impact on not only their lives and that of their families but also on their communities is profound. Within a mere 2 years after initial diagnosis, almost 80% of CKDnT patients suffer total kidney failure and ultimately die. Since a death represents not just the loss of a loved one, but also often the loss of a family’s main breadwinner, the consequences go beyond personal tragedy — families left in financial ruin, children forced to work rather than attend school, and rising crime rates.
Calm nurturing in more natural/peaceful environments, prayer, and the use of indigenous medicine employing certain herbal plants and mixtures combine to help in some cases, and I photographed in one such alternative of traditional medicine facility in the rural suburbs of Anuradhapura. While more advanced, interventionist Western medical approaches involving dialysis and transplants to treat CKDnT help to sustain life a bit longer, there is increasing desire for a more natural and less costly approach in Sri Lanka. Sterile and dehumanizing dialysis clinics, high medical costs, lack of specialist doctors and nurses, and a shortage of treatment facilities make death nearly inevitable for most of the poverty-stricken victims, even though this small country is doing a remarkable job in responding to this health crisis, more needs to be done.
Over the past 20 years, 23,000 people have died from and an estimated 69,000 have been diagnosed with CKDnT. Sadly, sympathy and support owed its sufferers often yield to indifference as political and economic interests shroud this vital health issue. As in other countries that share both the CKDnT epidemic and the apathy towards its victims, Sri Lanka must make this unexplained, fatal illness one of its most urgent environment-related national health issues. With environmental sustainability, human welfare, and simple survival of a civilization lying at the heart of current social movements, understanding and eliminating this mysterious killer is of global concern.