CKD in Rajaratasurfaced in early 90s: unpublished personal experience.


S.A.M. Kularatne,

Senior Professor of Medicine, Department of Medicine, Faculty of Medicine, University of Peradeniya.

The chronic kidney disease in Rajarata has become a contentious issue in Sri Lanka. At present, enough data are available to prove its depth and breadth. The evidence supports that CKDu has been spreading to all corners of the dry zone of the island which constitute about 70% of the land area. Many research groups have published epidemiological aspects of the disease somewhat in piecemeal pattern over last 15 years whilst unabated arguments on the causation of the disease continued. Hypothesis after hypothesis were put forward as the cause of the disease without solid proof. In a nutshell the whole issue has become "research politics". The pressure on the government to control the disease is apparent.

This issue needs holistic approach and target the research approach to the focal point very scientifically. Premature conclusions are detrimental and misleading. Without getting involved, I keenly observed the developments during the past few years expecting to see consensus on the root cause of CKDu found on scientific basis. However, it still remains a mystery. At this juncture, I thought of sharing my experience on CKD in Rajarata during my tenure as a consultant physician in the General Hospital, Anuradhapura approximately five years from 1994 to 1998. I hope my experience will help the researchers in CKDu in guiding their research activities in the correct direction and also help the authorities to arrive at appropriate decisions.

It was in August 1994, I reported for duty as a consultant physician in General Hospital, Anuradhapura where I was looking after ward 7, 4A and Medical Intensive Care Unit. I was one of the two physicians attached to the hospital and the workload was enormous. But, I enjoyed my day-to-day work. As I commenced my work, I found my wards were loaded with malaria, snakebites, organophosphate poisoning, yellow oleander seeds poisoning, Japanese encephalitis, typhoid and hepatitis as outstanding problems. I took special interest in managing these diseases. However, in 1995, there were sporadic cases of CKD inviting my special attention. Then, I realized numbers of CKD were increasing by 1996. In early 1997, I carried out an audit on CKD related deaths in my male medical ward. The results astonished me as more than 100 patients have died in 1996 due to CKD in my ward alone. Also I found most of these patients had come from places like Madawachchya, Padaviya and Kabithigollawa. I promptly shared these finding with the hospital authorities and my co-physician, Dr. Wasantha Kodikaraarachchi who incidentally was a batch-mate of mine in the university.

Dr. Kodikaraarchchi, informed me that he had made the same observation and he wished to initiate a field research programme to look in to it. I whole heartedly supported his research efforts. He organized a group of investigators and sent them to Madawachchiya to collect urine samples from healthy people from that area. Later, he told me that they had found abnormal urinary findings in many of those people exclusively in male gender. In 1998, I studied some more aspect of this emerging disease of CKD. Due to many constrains, these initial finding were not published and went under the dust of antiquity. During my stay, I saw the changing disease pattern in the region- declining Japanese encephalitis and emergence of dengue in 1997. I managed a massive outbreak of viral hepatitis among combating soldiers. Organophosphate poisoning remained as the dominant method of self-harm and I witnessed the first case of Glyphosate poisoning in the latter part of 1998. In December 1998, I left the hospital, but still enjoy nostalgic memories in Anuradhapura where I spent the best part of my life as a physician. Today, I take the opportunity of teaching my students on my first hand experience of treasure trove of medical conditions that I had come across in Anuradhapura.

Subsequently, my successors in the hospital engaged in more work on CKDu that helped to improve the care and awareness of the condition. I have been thinking about scientific approach to find the aetiology of CKDu. I had discussions with my predecessors in GH Anuradhapura and came to know that CKD was not an apparent medical problem in 1980s and even in the year 1990. This information rings the bell that in collation with my observation, CKDu would have emerged in early 90s and was in full swing by 1996. It is known that time lag between whatever renal insult to development of CKD could vary from weeks to years. Observing the incidence and prevalence of cases, I feel the above time lag should not be too long. The researchers need to think about what environmental changes had taken place in the dry zone from the early 90s by critical comparison to previous decades. Time should not be wasted as people who are living over these periods and witnessed the changes are getting old and are few in number. Even the documents to that effect would have been destroyed. The younger generation tends to ignore value of bequeathed knowledge. Even though, I refrained from writing my opinion on the causation of CKDu, I hope this essay would be useful for researchers and policy makers.

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