Agrochemicals, CKD  and vested interests


Dr. Channa Jayasumana

Department of Pharmacology
Faculty of Medicine
Rajarata University

This refers to the article written by Dr. C. S. Weeraratna (CS) on Feb. 10 and 13.

CKDu and CRF

In his first article, CS said Chronic Kidney Disease of Unknown etiology (CKDu) is also known as Chronic Renal Failure (CRF). Although CKD and CRF are synonymous neither of them is synonymous with CKDu. CRF is the pathology or the clinical syndrome due to CKDu. Conceptual clearance is very important for scientists. CS demonstrates incorrect judgment by being unable to differentiate CRF from CKDu.

CKDu in Sri Lankan setup is a well defined entity and there are criteria to distinguish a CKDu patient from a CKD patient due to other causes (such as diabetes, hypertension, infection, connective tissue diseases etc). Without trying to understand what I said, CS mentioned "CJ says that nowhere in the medical world is chronic kidney disease (CKDu) called CRF". What I said was: "Nowhere in the medical world is chronic kidney disease of unknown etiology called CRF". I request CS to please identify and understand difference between CRF and CKDu.

WHO report and CKDu

CS again says there are no conclusions in the WHO report. Yes, I am referring to the same WHO report and not surprised at his inability to find it. CS usually can’t find any ill effects of agrochemicals mentioned in a report, speech, or an academic paper. As repeatedly requested by CS I quote some of the conclusions in the said report,

"The Main Conclusions based on the analysis and syntheses of data obtained from studies up to now are,

* There is evidence of long-term exposure of people in these districts to low level of Cadmium.

* There is also evidence of chronic exposure to low levels of arsenic.

* In susceptible individuals, co-exposure to Cadmium and Arsenic is giving rise to more pronounced renal damage than exposure to each element alone.

* Contamination of the soil appears to be mainly from fertilizer and also from agrochemicals".

PAGE 124

I wonder how a person of this calibre made a statement to a national newspaper that he couldn’t find these conclusions in the report. If CS is keen enough to find out the recommendations, here they are:

Some Recommendations of the WHO Report

> Since the determinants of CKDu lie outside the health sector, set up a high-level inter-ministerial committee chaired by the Hon. Minister of Health to actively engage Ministries of Agriculture, Water Supply, Irrigation and Social Services to implement multi-sartorial policy remedial actions proposed.

> Scale up water purification schemes and provide water to households in the endemic area for drinking and cooking purpose.

> Strengthens the regulatory framework to improve quality control of imported agrochemicals particularly with regard to nephrotoxic agents such as cadmium and arsenic i.e. amendments to existing legislation, capacity strengthening for implementation and monitoring.

> Implement and monitor comprehensive public measures to reduce the exposure of farmers to harmful health effects of agrochemicals through:

> Education on the appropriate use of fertilizer

> Compulsory provision of safety clothing, gloves and asks at the point of sale of agrochemicals

> Control of sales of agrochemicals which are known to be nephrotoxic. Propanil, Chlopyrifos and others.

PAGE 125

Water Hardness and CKDu

I have categorically asked CS to point out DS divisions in NCP where agrochemicals are used in large quantities and groundwater is hard but CKDu is not reported. He couldn’t point out such a single DS division. Instead, he says there are 15 DS divisions where number of CKDu cases reported lower than 100. This is a fact I pointed out from the beginning. Patients are not spread homogeneously throughout the endemic area but in clusters.

Higher numbers of patients are being reported from the places with high ground water hardness. The reason is the amount of nephrotoxins retains is directly proportional to the degree of hardness. Initially patients were reported in the villages with highest ground water hardness is present (> 500mg/L) eg-Sripura, Padaviya, Medawachchiya, Medirigiriya, Giradurukotte. However, now patients are being reported from places with ground water hardness is in the mid range (300-500mg/L) e. g. Rajanganaya, Eppawala, Dambulla, Elahera, Dimbulagala, Wellawaya, Monaragala.

On the basis of our theory I predict there is a risk of the disease spreading to the farming areas with ground water hardness is in the range of 150-300mg/L in the near future such as Mahawa, Nickaweratiya, Polgahawela, Nawula, Thissamaharama. Other important factor I want to emphasise is the mere presence of high groundwater hardness in a farming area (where agrochemicals are used extensively) is not enough; people fall sick only when they drink the contaminated hard water. In Saliyapura, where Rajarata Medical faculty is located groundwater is hard, chemicals are extensively used but patients are not reported. The reason is Saliyapura is provided with purified drinking water from Nuwara Wewa and, therefore, the inhabitants do not drink groundwater. Surface water in the Nuwara Wewa is not hard.

The low concentration of a cumulative nephrotoxins coming from hard water and its bioaccumulation could have taken 12–15 years to cause damage to the kidneys leading up to the level of clinically identifiable CKD. The increase in prevalence of CKDu and the shifting of age at diagnosis to younger age groups over the years are highly suggestive of the cumulative nature of the toxin. Political changes effected in 1977 in Sri Lanka, paved the way for economic policies that allowed the importation and application of agrochemicals on a large scale, especially for paddy farming. That is the reason why the disease was first reported in mid 1990s.

Then CS asks why there are no patients reported from the North although water is hard. The answer is very clear. A comparatively low amount of agrochemicals has been used in the Northern Province of Sri Lanka for last three decades or so, primarily due to restrictions on agrochemicals in view of the conflict. For, they were used to produce Improvised Explosive Devices (IEDs). Now farmers in Vanni and Jaffna peninsula are using agrochemicals and hence, we predict this epidemic will emerge in those areas in the future.

I challenge CS to name a single place in NWP and Uva where CKDu is reported but water is not hard. In his reply, CS has not mentioned a single word about this matter and now talking about Hambanthota. How does he know that there are no CKDu patients reported from Hambantota? If he is interested enough, he can contact the Nephrologist in Karapitiya Teaching Hospital and inquire about CKDu in Hambantota (usually CKDu patients in Hambantota are referred to Nephrologist in Karapitiya). Further, we have found a significant number of CKDu patients from Hambegamuwa a farming scheme close to Hambantota, where groundwater is very hard and agrochemicals are extensively used.

The observation CS uses to reject agrochemicals and hard water as a key factor responsible for CKDu is very poor. Earlier he mentioned Mahiyanganaya. Now he is pointing out hardness levels in Nickawewa. Even in an endemic area, the groundwater hardness is different from place to place. There are places in Padaviya, Kebitigollawa and Madavachchiya, where groundwater is not hard. Best example is the natural water springs in Kebitigollawa. People who consume water from these sources have been found to be free from the disease. No one should rush to conclusions on the basis of the average groundwater hardness in an area. In Nickawewa there are some water sources with total hardness level exceeding 1000mg/dl.

Then CS wanted me to specify what the agrochemicals responsible for CKDu are. Here is the answer:

* Any agrochemical which contains arsenic and heavy metals (Cadmium, Chromium, Nickel, Lead, etc) is responsible.

* Any pesticide, which can easily form complexes with hardness, is responsible. Glyphosate is the unique example. The Stauffer Chemical Company–USA initially obtained a patent for aminophosphonic acid as a chelating agent, wetting agent and biologically active compound in 1964. Glyphosate was initially used as a de-scaling agent to clean out calcium and other mineral deposits in pipes and boilers of residential and commercial hot water systems. De-scaling agents are effective metal binders, which grab on to Ca, Mg, etc. ions and make the metal water soluble and easily removable. Later, the Monsanto Company acquired the chemical from Stauffer and obtained a patent for aminophosphonate for its herbicidal properties. Glyphosate is the most widely used herbicide in the disease endemic area.

* Any pesticide which is already known to damage renal tissue is responsible such as Chlopyrifos, Propanil.

In my previous article, I requested CS to visit Mahiyanganaya and Giradurukotte and feel the hardness of water as he said water in this area is not hard. Now, he says he has visited Nikawewa and Plolpithigama during his stay in Anuradhapura. I don’t know how someone can be familiar with Mahiyanganaya while visiting to Nikawewa and Polpithigama which are located some 150 km away! If this is the same logic he uses to comment on my theory, I feel very sorry for CS who has been repeatedly expressing inconsistent views to safeguard agrochemicals incriminated in CKDu epidemic in Sri Lanka.

Further CS says, "It is not possible to accept CJ’s theory that agrochemicals and water hardness are solely responsible for CKDu". What does this mean? Does CS think agrochemical and water hardness are partially responsible for the epidemic. If so, what are the other contributory factors? I request CS to please reveal all responsible factors in CKDu without any delay as we can advice innocent farmers in the region to avoid them. As far as I know, CS has neither done any research related to the CKDu issue in Sri Lanka nor has he furnished any publications on CKDu. Hence it s better to mention the evidence he has used make the above statement.

In the last paragraph of his response CS says it is important that scientists refrain from citing unconfirmed unscientific ideas which tend to give wrong information to the general public and policy makers. In fact, now the reader can decide who has cited unconfirmed and inconsistent ideas. Further, he has intentionally hidden the data in published documents in favour of his view.

While researching to find out what causes CKDu and how to prevent it, I have met so many people. There were genuine people who constructively criticised our ideas, hypotheses and theories and somehow wanted to contribute to control the epidemic. At the same time there were people with vested interests. I know who these people are. That is why I have mentioned it is very difficult to wake up people who pretend to be asleep.

I don’t think I can convince CS of the link between CKDu epidemic in agricultural communities in Sri Lanka and agrochemicals even by writing hundreds of articles in The Island. Many investigators have already provided enough scientific data to show agrochemicals are playing a role in the pathogenesis of CKDu. We have pointed out them out in various meetings held in the last couple of years. CS was a regular participant at those meetings. He behaves as he if he had accepted the facts but later he begins from the beginning. There is need to reinvent the wheel. Hence, I would like to invite CS to an open discussion or a debate on the link between CKDu and agrochemicals. If he accepts my invitation I will arrange for the debate at Rajarata University and personally reimburse CS’s transport expenses etc. Or, I am willing to come to a place of his choice.

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