A mountain overlooks scenic rice fields near Aluth Oya, Dimbulagala district, near Polonnaruwa, Sri Lanka on June 30, 2016. ©Ed Kashi / VII

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.

Link to the entire set of images in the VII Archive

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.

Students line up to be tested for CKDu at their rural secondary school in Rajanganaya. With the support of the government, a local CKDu organization performs a mass blood screening of 342 students. This area of Sri Lanka, in the North Central Povince, is the hot zone for CKDu in the country. © Ed Kashi / VII

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.

A farmer prepares herbicide for his rice fields to prepare them for planting in the village of Kongahanagama, in the North Central Province of Sri Lanka on June 28, 2016. Pesticides are considered one of the primary causes of CKDu, a disease that afflicts primarily agricultural workers in hot, poor countries. © Ed Kashi / VII

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.

Patients check in with the receptionist at the Medawachchiya Hospital in Medawachchiya, Sri Lanka on July 4, 2016. Every Monday, Wednesday and Friday people with kidney problems come to here for clinical checkups and monitoring of their CKD and CKDu (chronic kidney disease of unknown origin). This area of the North Central Province of this country is the epicenter of CKDu, with nearly 20% of the population suffering from this disease. People come for their monthly checkups, anxious to get the treatment and support they need so avoid dialysis. © Ed Kashi / VII

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.

Patients receive dialysis treatment in the Anuradhapura Teaching Hospital’s dialysis clinic. © Ed Kashi / VII

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.

Adman, 62, is cared for by family members at home in the village of Theriyankulama, Sri Lanka on July 4, 2016. K. Adman and his son, Anushka Adman, 31, both suffer from CKDu. The father was a rice farmer and his son was diagnosed with CKDu at 17 years old and has been on dialysis since he was 18. His father tried to donate a kidney and it was then that they found out he has CKDu too. © Ed Kashi / VII

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.

Link to the entire set of images in the VII Archive