In the NCP, the implementation of RO plants began after 2011. According to Ranasinghe et al [1], a notable decline in the prevalence of hospital-diagnosed CKD/CKDu was observed in 2020 relative to previous years of 2016 – 2019 in 25 out of the 29 Divisional Secretary Divisions, coinciding with the provision of RO drinking water to over 20% of households. However, looking at the data provided in the article, shows that since 2013 well over 20% of households were provided with RO water, and in 2021 it was 68.3% of households were provided with RO water. Yet the Spearman correlation is weak as shown before showing that there should be other factors contributing to the decrease of CKDu incidents over the years.
Our analysis of data in 2021 shows that the decline in CKDu rates first became evident around 2016 [3. see fig.2], although Table 1in Ranasinghe et al shows incidence in 2016 was higher than in 2015. Subsequently, I posit that the incidence of CKDu has continued to decline since then, with the growing adoption of RO water for drinking purposes by every household as shown in [3].
Since it was first identified in 1990 in Medawachchiya in NCP, about 23% of the population of NCP has fallen sick with CKDu [20]. Not only that, but the disease has spread to bordering districts as well.
Since 2013, CKDu has been linked by Epidemiologists, and the local people to polluted drinking water. When I started fieldwork in Medawachchiya in 2013, people there told me that they got the disease because of polluted water or ‘kivul’ water that they drank from the shallow wells and tube wells. that emitted a foul odor, had a musty taste, and appeared bluish. The new interest of the government and research findings of epidemiologists and biomedical scientists are driven by lay ideas about a link between CKDu and contaminated drinking water with foul taste (kivul). As proved later by scientists, the views expressed by people were correct [21].
With the rise in the number of CKDu patients, in 2009 , the government of Sri Lanka declared CKDu an emergent disease, with the histological appearance of the disease being tubulointerstitial [21, 22], necessitating intervention from the Ministry of Health. Responding to the urgency of the situation, the government took proactive measures to cater for the ever-increasing CKDu patient population in the Anuradhapura district in NCP. The most important of the measures taken by the government included the construction of 23 nephrology clinics in the Anuradhapura District and the posting of trained nephrologists to regional hospitals and clinics in the affected areas, signifying a concerted effort to address the growing CKDu crisis.
The focus of the government originally has been on treating patients rather than addressing the root cause of the disease, which is polluted water . This was partly due to the wavering opinions and findings on the causation of the disease. Scientists who worked on the question of causation came up with various explanations. (Jayatilake et al [20] argued that CKDu is due to cadmium exposure through the food chain and drinking water. Cadmium gets into drinking water, local foods, and fish through the application of fertilizers and pesticides in waterlogged paddy farms and vegetable gardens. Other potential causal factors suggested by epidemiological research in the NCP include elevated levels of fluoride in drinking water, groundwater hardness, and the accumulation of heavy metals in soil due to factors such as fertilizers, pesticides, and toxins produced by cyanobacteria, commonly referred to as blue-green algae [21, 22]. It is well-documented that drinking water serves as a significant route for the transmission of heavy metals like arsenic and cadmium [23, 24, 25, 26, 27]. Bandara et al. [24] observed notably high cadmium concentrations in Mahaweli River water (ranging from 0.03 to 0.06 mg/L), sediments (1.78 to 2.45 mg/kg), and local food within CKDu endemic areas of the NCP. Findings suggested that shallow well and tube well water in the Anuradhapura District contained excessive cadmium, potentially due to irrigation water draining into shallow wells below reservoir and canal levels [28, 29].
Conversely, researchers from the University of Kelaniya posited that arsenic from fertilizers, herbicides, pesticides, and glyphosate, along with the hardness of drinking water, contributed to CKDu. They demonstrated elevated levels of arsenic in local foods such as rice, tilapia fish, and lotus roots [30, 31, 32]. Additionally, scientists from the University of Peradeniya [33, 34] proposed a correlation between the geographic distribution of CKDu and fluoride levels in drinking water. The new interest of the government and research findings of epidemiologists and biomedical scientists, driven by lay ideas about a link between CKDu and contaminated drinking water with foul taste (kivul) , provided the basis for government action and a research agenda. The construction of a new discourse around the disease defined it in biomedical terms as one caused by environmental factors.
The narrative around the etiology of the disease emphasizing the role of environmental toxins gained momentum through media coverage and political discourse [3]. This spotlight prompted significant public outcry, leading to governmental initiatives to provide alternative drinking water sources. Although empirical studies investigating the efficacy of alternative drinking water sources at the community level are lacking, some research has delved into this area through laboratory experiments and case-control studies.[35] conducted a laboratory investigation to assess the impact of high fluoride levels and elevated water hardness on rats' renal and hepatic functions. They administered water samples collected from CKDu endemic regions orally to the rats and examined whether distilled water could mitigate the observed damage. Their findings suggest that early-stage kidney damage may be reversible with the introduction of distilled or low-solute water.
The Commercialization of Drinking Water
The understanding that contaminated water contributes to CKDu originates from firsthand experiences. People's observations of water's odor, color, and texture, the residues left in kettles after boiling, and the corrosion of aluminum pots when stored, provide tangible evidence supporting the belief that drinking water is the primary cause of illness. As awareness of water's role in CKDu expands, traditional water management systems, rooted in collective property management principles, transitioned towards individualized management, particularly regarding drinking water.
In Anuradhapura, this shift towards individualized drinking water systems entailed purchasing bottled water or buying water by the liter from water shops, as well as utilizing monthly water delivery services by private vendors. Rainwater harvesting at home and collecting water from natural springs, predominantly practiced by low-income families, further illustrate the trend towards individualized water acquisition. Consequently, drinking water has become a commodity, necessitating financial investment and personal effort by individual households [32].
This transition has led to the emergence of businesses in urban areas where empty plastic containers are sold to those in need. In rural villages, small shops sell water in plastic bottles and larger containers. Farmers now transport water from home to irrigate rice fields and avoid consuming water directly from canals. Similarly, schoolchildren carry water bottles, choosing not to drink from school wells or nearby taps. These shifts underscore the commercialization of water in Anuradhapura, where obtaining water for domestic use requires individual initiative, financial resources, and agency.
Particularly after 2008, when a WHO team commenced their research on CKDu, the local health department of the District initiated a range of actions in the villages. These included testing water quality in dug and tube wells, conducting blood and urine sample tests, and educating villagers about various preventive measures. These measures encompassed the importance of safe drinking water, the judicious use of pesticides, and the avoidance of locally grown vegetables and fish [32].
The implementation of health education initiatives, administered through village health committees known as "suvasahana kamitu," has been instrumental in this endeavor. These programs were meticulously tailored to disseminate knowledge among rural residents regarding preventive measures and the care and treatment options made available by the health ministry. Public Health Inspectors (PHIs) and midwives assumed pivotal roles in community engagement, endeavoring to effect behavioral changes in water consumption. Their concerted efforts have significantly contributed to the diminished prevalence of CKDu.
The district offices of the Medical Officer of Health took the lead in extensive campaigns aimed at educating villagers about the significance of using clean drinking water. These efforts advocated adopting RO water purification systems within these communities. The collaborative work of PHIs and midwives played a crucial role in instilling confidence among villagers, a pivotal factor in their transition to using RO water. As expressed by one informant, ‘
they organized meetings.’ They said 'We are confident we can combat the disease. We trusted them because of their expertise in the field.' Consequently, we opted for RO water.’ Another informant endorsed the effectiveness of RO water, citing the alleviation of their symptoms of burning urination after consuming it, a sentiment echoed by numerous interviewees. Significantly, 90% of respondents who had previously reported experiencing burning urination confirmed its cessation after adopting RO water consumption practices. People often commented on the odor, color, and consistency of water from wells and Tube wells and the presence of sediments. Boiling well water resulted in the formation of sediments (referred to as 'mandi') resembling cement in the kettle, eventually leading to the development of holes in kettles and aluminum pots used for boiling and storing water. A 32-year-old woman from an agricultural settlement remarked, ‘When we pour well water into aluminum pots (kalaya), holes start appearing at the bottom of the pot… if this water can corrode the pot, just imagine its effect on our bodies when we drink it.’
The transformation of well water, once revered for its symbolic significance and role in religious rituals, into a source of disease and mortality, marks a profound shift in perception. Sentiments expressed by informants poignantly capture this evolution: ‘We drink water because we must live… whenever I drank water from a well, I felt like I was drinking poison…’; ‘Now, I don't take water from the well to bathe the Bodhi tree in Anuradhapura… I use water from the natural spring instead…’; ‘Now we never use well water for water chanting… (watura maturanava)’; ‘When food is prepared to be offered to monks in the temple, they ask us not to use well water for cooking; …now in my daily offerings (dana) to the Buddha statue at home, I don't use well water as pän [drinking water offered to Buddhist monks]’; ‘Now we don't use well water for cooking or drinking.’ Many informants noted significant reductions in water consumption as a consequence.