The tragic kidney disease affecting the people of the north-central province has recently been highlighted in the media. Latest development in this has been the decision by the Minister of Health to seek the help of the WHO in identifying the cause of the disease after the failure of the doctors here to identify a definitive cause. During a recent meeting where the Minister of health and a number of physicians who are actively involved with this project participated, some startling facts emerged. One is that this problem has now reached almost epidemic proportions where a concerted national effort is required to deal with the issue, just like the way we battled malaria in the same areas several decades ago. Unlike malaria, this kidney disease requires a truly multidisciplinary approach to solve and it should not be left only for the doctors to find out the reasons for its occurrence. While the work of doctors like Tilak Abeysekera and Nimmi Athuraliye have established the nature of the disease, we are far from understanding the exact reasons for the occurrence of this dreaded condition which is commonly referred to as Chronic Renal Failure (CRF). A task force of scientists should be immediately established to find out the reasons for its occurrence where a scientific investigation of the risk factors should be carefully and systematically investigated. Scientists should now take over the bulk of the work and study all aspects of the issue. There is also a fair amount of unscientific theories appearing in the print media which can be distracting and counter-productive. This article is an attempt to shed light on the nature of this problem and also discuss some of our own research results on possible causes for this disease which will benefit the population in the affected areas.

During the last two decades, alarmingly high incidences of kidney failure and some associated deaths have become very significant in certain parts of the Anuradhapura District. These came to light after the revelations in and around 2002, which appeared in the local press of "a kidney disease with unknown reasons". In the Padaviya AGA division alone, 184 such cases and 22 deaths due to the same reason have been reported during the period 1999-2005. During the same period and for the whole of Anuradhapura district, the number of incidences was 4095 while the number of deaths was 577 according to the Provincial Ministry of Health, North Central Province.

Chronic renal failure (CRF) affecting the north-central province (NCP) results in the premature deaths of otherwise healthy people. People affected are mostly farmers who live in rural areas of the district. Once detected, there is no cure other than a transplant which too is not an ideal cure. Admission of patients to the Anuradhapura hospital with CRF which was 13% of all cases in 1999 increased gradually to 23% in 2003.

Balkan Endemic Nephropathy (BEN) refers to a very similar chronic renal failure incidence in several countries of the Balkan region including Romania, Kosovo, Boznia. After the doctors identified its salient medical features, scientists from both the region and also from the US Geological survey undertook research to investigate possible causes. Again, several possible causes were identified but the two main ones were; action of a toxic fungal metabolite (a mycotoxin) from fermented foods, and secondly, toxic organic compounds leached from Pliocene lignite rocks. Pliociene lignite is something closely related to coal in its composition. Now, it is generally accepted by the scientists involved, that the toxic polyaromatic hydrocarbons from the spring water running through the lignite rocks are responsible for BEN. It took nearly 30 years to crack this case, involving hundreds of scientists and this illustrates that solving problems like these are is no easy tasks. Endemic Nephropathy in this part of the world such as what we observe in the NCP has received little or no attention. Some of the medical and epidemiological features of this type of nephropathy from the Anuradhapura district are quite similar to Balkan Endemic Nephropathy such as; incubation period with a rapid onset of end-stage renal disease, at least 15-25 years of residence in an endemic village, occurrence mostly in adults in the age group of 30-45 years while no children or individuals above 65 years develop the disease and no association with hypertension or diabetes. Although originally it was thought to affect only males, most of them farmers, subsequent studies showed no such gender preference and not even an association to their vocation.

Doctors from the University of Peradeniya and Dr. Tilak Abeysekera who did a fair amount of work on the nature of the disease have established that this is not due to the common reasons ascribed to CRF, namely, high blood pressure and diabetes. Therefore, it is quite likely that CRF in the north-central province could be due to the result of the intake of some toxic and detrimental constituents in the drinking water (or food). There are a number of such elements and constituents that can be present in the water and prolonged exposure to these in drinking water may result in damage to the kidney.

There was a meeting called by the Water Board in Anuradhapura in February 2003 to discuss the ideas of a cross section of professionals including health professionals and scientists to discuss this problem since it was generally thought to arise from the water that these people drink and some toxic elements are getting into their bodies through water. At that time there were several theories about possible causes and some of these are; pesticides, alcoholism (locally brewed illicit liquor) and snake bites. At that time, the Water board requested our help to investigate this problem and this study commenced in 2004 along with the participation of a senior hydrogeologist, Dr. H.A. Dharmagunawardhana of the Geology department, University of Peradeniya to scientifically study the geo-environmental factors which may have an effect on the prevalence of CRF in the North-central province.

Anuradhapura district being a part of the dry zone of the country, the vast majority of (rural) population depend both on groundwater and surface water sources such as dug wells, hand pump-tube wells, irrigation tanks and channels etc. for their domestic water supplies. It was found that the majority of the people use water from dug-wells. Preliminary examination of several water samples from this region showed nothing wrong with the quality of the drinking water. However, there was one problem; most of these well water samples had high fluoride concentrations. This was already known to the scientists of the Water Board as the cause for the incidence of dental fluorosis in the area resulting in the discolouration of teeth. Several pioneering projects undertaken by Mr. J.P. Pathmasiri who was the Chief Chemist at the Water Board at that time to have low-cost fluoride filters to reduce fluoride in water have produced excellent results in preventing dental fluorosis in some areas. However, since dental fluorosis is not a life threatening condition, people generally ignored the need to remove fluoride from their drinking water.

Role of pesticides ?

There is widespread use of pesticides in these agricultural communities. Occupational hygiene practices are quite unsatisfactory and contamination of the human body with pesticides through the skin is a common occurrence. There is also the potential for drinking water contamination through agricultural runoffs. Pesticides are accumulative poisons and the common adverse health effects include chronic pulmonary diseases and bronchitis while there are only a few reports on the effects of pesticides on kidneys. Exposure to low levels of pesticides over a long period of time may result in damage to renal tubules. Due to these reasons, pesticide monitoring was also undertaken on a number of representative drinking water samples from the affected areas of the NCP. They were analyzed for the presence of pesticides such as dimethoate, chloropyrophos and diazenon which are commonly used in this area. The levels of pesticides in these samples were well below the stipulated WHO water quality standards for pesticides in at least 100 samples of drinking water collected from the affected region. Field investigations further revealed that many of the dug /tube wells that have been used by the renal failure patients were situated quite far away from the paddy fields or other vegetable plots and therefore risk of contamination of water due to pesticides is minimal. The theory that pesticides are responsible for this situation is a weak argument since the use of pesticides is equally prevalent in other parts of the country such as the southern province where there is no such abnormally high occurrences of CRF.

Another theory that has been put forward by some is the consumption of Tilapia fish and the cadmium concentration in them as responsible for CRF. However, this cannot explain why people in Anuradhapura town who consume this type of fish from the large tanks in Anuradhpura do not get this disease. Even at Padaviya, those who live in town close to the Padviya tank do not show this phenomenon and only those who live away from such large tanks and obtain water from shallow wells are susceptible. Furthermore, those who consume Tilapia fish in the southern province do not get this and hence it is difficult to accept this as cause for this CRF condition. It is also dangerous to spread such unsubstantiated stories since the only cheap source of proteins in these areas is Tilapia fish and this will have implications in the health of these people by creating protein deficiencies in their diet. Chemical analysis of Tilapia fish caught from the affected areas were analyzed at the Industrial research Institute (ITI) and the University of Ruhuna who found no such cadmium contamination in the north-central province compared to the other areas of the country. Thus, people in the province need not stop eating Tilapia fish, perhaps their only source of protein in the absence of alternatives such as sea fish and dried fish which are exorbitantly expensive these days.

Thus, the only logical explanation as to why only people in only certain geographical locations get this disease is the occurrence of fluoride in drinking water. Of course one can argue till the cows come home that this has not been proved beyond doubt. It is, of course still at the hypothesis stage in the scientific method hierarchy and needs further input from other scientists to elevate up to an acceptable theory. This hypothesis based on fluoride does not contradict any of the findings accumulated so far based on scientific studies. Those who live in the city limits of Anuradhpura get their water from water schemes where the tank water is supplied by the water board. This is Maheweli fed water and also rain water, both having very low levels of fluoride (less than 1 part per million). Such low fluoride levels are also observed from the water from wells close to such large tanks where the ground water in wells gets continuously mixed with low fluoride containing water. Similarly, those people living close to Padaviya tank who use well water still get their water effectively replenished from the tank water thereby reducing fluoride levels. This explains very well why the prevalence of CRF is quite small for people living in close proximity to the Padaviya tank.

Several years ago, after finding that high fluoride levels may be responsible for CRF, we studied the factors which can enhance intake of fluoride into the body and we discovered that one key component involved was aluminium. Without exception these people in the affected areas use cheap quality aluminum utensils for cooking, boiling water for tea and for storage of water. It was quite by chance that we observed the holes appearing in some of the used pots and also how such holes are soldered with highly poisonous lead. Having followed up the water fluoridation controversy in the USA and also some scientific work carried out in Sri Lanka on the dissolution of aluminium in the presence of fluoride, this chance observation immediately struck me as something specially significant. From a scientist’s point of view, aluminum forms complex compounds with fluoride which can penetrate the blood-brain barrier and finally end up in our living tissues. In effect, aluminium acts as a fluoride transfer agent to transport it through all biological barriers and deposit them in our body where it can influence body functions. Effects of fluoride and aluminum on the kidney are well documented and in experimental animals they are known to have a profound effect on the renal tubules. If the fluoride levels are so high to create holes in aluminum utensils then we have a real danger here. We went one step further and got samples of aluminum wares found in these households analysed at a reputed laboratory in the USA and to our shock we found that the so called aluminium pots contain a wide range of heavy metals including the highly poisonous lead! In addition, lead is frequently employed to seal the holes of pots which are damaged due to continuous use. Lead based solder is employed for this purpose which results in an additional burden of lead into the body. Now, lead is an accumulative poison which too can affect the kidney. I tried my best to educate the public against the use of sub-standard aluminum pots along with the danger of using such pots with fluoride-rich water but this did not receive the attention it deserved. People were advised to use fluoride filters which were earlier popularized in a campaign to prevent fluorosis. We were also able to distribute about 200 such filters to people in some villages around Eppawela (with a generous contribution from the private sector) whose drinking water showed excessive fluoride levels and with a large number of people showing protein-urea in their blood tests.