Phepro

Foundation for Preventive Health, Environmental Protection and Research (PHEPRO.org)

Goal: To Eradicate Chronic Kidney Disease (CKD) from the North Central Province of Sri Lanka

Click here for full details about the water sanitation project currently underway to combat chronic kidney disease.

The Foundation for Preventive Health and Environmental Protection (PHEPRO.org) is a national and international coalition with the mission to eradicate chronic kidney disease of multi-factorial origin (CKD-mfo) [also known as CKDu, CKDuo, and CKDue/a], from Sri Lanka. The steering committee consists of concerned Sri Lankans with diverse expertise.

The PHEPRO Foundation is responsible for the longer-term project implementation and financial management. The structure and the registration of the foundation “PHEPRO.org” is currently being worked out. Click here to view the board of directors.

During the last two decades, Sri Lankans have experienced an escalating incidence of chronic kidney disease (CKD) of unknown etiology in dry zonal areas. Similar incidences of unusual CKDs have been reported in the dry zonal, agricultural areas of several other equatorial countries. In Sri Lanka, the incidence of CKD-mfo is highest in the North Central Province (NCP), where approximately 45% of the country’s paddy fields are located. However, in recent years the disease has spread into areas adjacent to as well as distant from the NCP.

The cause of CKD in Sri Lanka is unknown but likely is of multifactorial origin (CKD-mfo). Part of the underlying reasons includes over-exploitation of land and water, indiscriminate use of agrochemicals that damage the environment, leading to non-communicable diseases including CKD-mfo in this region.

If we select men and women of proven capacity, honesty, integrity, and efficiency to manage our projects, the economy, and the country, more efficiently and productively, economic development and the prosperity will occur. Therefore, there is no reason to opt for inferior options.

Background

Because of changes in the climatic patterns, predominantly attributable to human interventions such as land settlement, deforestation, and overuse of agrochemicals, the ecosystem in Sri Lanka is under unprecedented pressure that threatens prospects for sustainability and the welfare of today’s generation and future generations.

According to data of the Water Supply and Drainage Board, only 45% of households in Sri Lanka have a pipe-borne water supply; the other 55% rely on tanks, streams, and wells for drinking water. In the North Central Province (NCP), most of these water supplies are polluted.

Causes and incidence of CKD

Although a specific cause of CKD is unknown, the disease in the NCP is thought to be a soil-water –related environmentally acquired disease caused by the consumption of polluted and contaminated water. The food supply is secondarily contaminated by the water contamination. Adverse environmental conditions, irrigation systems, agricultural habits, and excessive agrochemical use may play a role in causing this disease, but the industrial mechanisms cannot be underestimated.

Despite implications that other factors, such as heavy metals (cadmium, arsenic), fluoride, algal toxins, agrochemicals, hard water, ionicity (solutes in the water), glyphosate, Ayurvedic drugs, snakebites, tobacco and illicit liquor, and inadequate water intake, could be the culprits in CKD, there is are adequate data or credible scientific evidence supporting these theories. At currently reported exposure levels, none of the mentioned substances alone would cause kidney failure.

The Problem the Project Is Designed to Address

Financial and technological constraints, on the one side, and disparities between national policies and practices on the other are significant deterrents to attempting holistic interventions. The NCP desperately needs a cost-effective way to provide clean water for its populace and ways to prevent additional environmental pollution, particularly of the water supply.

Recommended Solution

A centrally purified pipe-borne water supply would be the final solution, but this is likely to take more than four decades. By then, an estimated 250,000 people in the NCP, mostly middle-aged male farmers, and an additional 100,000 people in other affected areas will succumb to CKD. This not only would devastate individual families and villages, but also would dramatically affect the economy through national rice production and the labour supply. In addition to controlling environmental pollution, it is essential to implement an interim solution that provides adequately purified potable water to these communities as early as possible.

Installation of Reverse Osmosis Plants

We have extensively investigated potential causes and solutions, and found that the reverse osmosis (RO) method is the best, most cost-effective, environmentally friendly, and sustainable option for providing drinking water to NCP villages in Sri Lanka.

However, not all RO units are the same. RO units come with capacity of producing 250 to 500,000 litres of purified water daily, but the quality of output water varies, depending on the material used in the manufacturing of RO units. Therefore, it is important to install the proper RO unit, using the ideal purification membrane and pre-filters for a given village.

For this project, we will be using “standardized” RO plants that have a capacity of 20,000 litres per day [~4,500 gallons per day (GPD)]. Each of these plants will provide clean water for an average village of between 800 and 1,800 people. RO is the most economical, easy to use, and durable option and requires the least maintenance. Using standardized RO plants, we minimize the future costs of replacement parts, including purification membranes for RO units. It is critical that the RO units the Foundation purchases are easy to install and maintain.

Smaller capacity units, with output of 250 to 500 litres/day are adequate for only 20 to 50 families and are too expensive relative to output. Moreover, these RO units would not function for more than 3 to 5 years. Higher capacity units that provide more than 100,000 litres/day are durable but too expensive for our needs. The output of clean water from these larger units is adequate to cover 15 to 20 villages; however, if such units are installed, women and children will have to walk, on average, two to five kilometres each day to obtain clean water from the centralized stations, potentially preventing a significant number of villagers from accessing clean water. Our objective is to provide easier access to clean water to all, in a practical and affordable manner.

Requirements and the Cost of Installation of RO Plants

Our extensive research into RO and a number of estimates received indicate that the quality of the US-manufactured RO units is far superior to that of others and more cost-effective in the long run. Less expensive units may not last more than 3 to 5 years, adding cost in the long term. The Foundation wants the units to last 25 to 30 years, providing water for villagers until the Water Board is able to provide a centrally purified pipe-borne water supply to the NCP region.

On average, RO plants that provide 20,000 litres of clean water a day are adequate to supply approximately 1,800 people (one large village or two to three clusters of villages) and cost approximately US $8,500 to purchase, install, and maintain. The region requires approximately 600 RO plants, at a total cost of US ~$5.0 million. For further information, please visit the following URL, which includes the 2013 Col. Olcott Memorial Oration text:

http://www.anandacollege.net/document/14011809Olcott%20Oration%20Book.pdf

The Operation Costs

The estimate for RO units includes purchase, installation, and maintenance of the machines for five years. The key maintenance cost is the replacement of purification membranes. The frequency of the need for replacement depends on A) the quality of the membranes and the RO units, B) the quality of the pre-filters, C) the quality of the locally available water supply, and D) the frequency and the quality of technical maintenance of the units. Purification membranes will deteriorate during storage in the NCP climatic conditions. Therefore, our purchase contracts include an agreed-upon price for the future supply of pre-filters and purification membranes.

The two additional operating costs are A) electricity for running RO pumps and B) individual operator payments. As an alternative option for item A, we are exploring the possibility of having solar-powered pumps for the RO units because many parts of the NCP do not have grid-based electricity and the electricity supply is unreliable. Operator costs will be recovered in one of several ways, depending on the village location and the cost-recovery model used. We will also build into the model a mechanism for providing water to public community areas, especially schools and places of worship, free of charge. We will ensure the operations of individual RO units are self-sustaining. The professional maintenance of these plants, including replacing membranes over the next 25 years, requires an additional US $2.5 million. The end users will generate this in a sustainable manner.

Sustainability of RO Units

We propose several models for the longer-term maintenance of the RO plants, including (A) complete control and maintenance by village community-based organizations (CBOs); (B) maintenance by the PHEPRO Foundation, with full-time employed technicians for maintenance of the RO units across the NCP; or (C) contracting a private company to provide long-term maintenance for units throughout the region. Whatever the choice, we will ensure the long-term stability and sustainability of the RO units.

Education, Awareness, and Pollution Prevention Campaign

The Foundation will conduct village-based, region-wide awareness and educational campaigns that (A) educate about the consequences of drinking contaminated water, (B) encourage using safe and clean treated water, (C) encourage water conservation and prevention of environmental pollution, and (D) encourage the use of locally available organic substances and compost for cultivation and pest control. We have an ongoing, since 2008, village-based educational and informative campaign in the NCP that we plan to intensify.

Why the provision of clean water is important:Villagers in the NCP who drinking water from natural springs do not have CKD-mfo. Irrespective of the cause, the incidence of CKD-mfo has decreased in villages where Water Board has supplied water for the past two years, using bowsers,

The sub-programs to be implemented and the budget:

Achieving the proposed objectives via implementing these six sub-projects:

  • Project 1: Educating all health professionals (English, Sinhela & Tamil booklet) [Budget US $33,280]
  • Project 2: Providing water-quality measurement devices & educating their use [Budget: US $22,000]
  • Project 3: Providing education including printing posters to increase awareness [Budget: US $50,000]
  • Project 4: Alleviating poverty & malnutrition, creating jobs, preventing disease [Budget: US $500,000]
  • Project 5: Developing and funding a network of locally relevant CKD research for [Budget $400,000]
  • Project 6: Purchasing, installing, and maintaining RO plants [Budget: US $5.0 million]

Initial target funds to complete sub-projects 1, 2, and 3 are US $105,000.

Due to the extensive nature of work, we expect 15% administrative costs for the project.

Total project cost: US $7.0 million.

Rationale for Six Sub-Projects:

The provision of clean water [Project 6], although essential, is by itself not sufficient to eradicate CKD-mfo from the country. It is essential to provide the right information to healthcare professionals regarding ways to eradicate the disease [Project 1]; for the public, efficient and cost-effective ways of identifying and quantifying polluted water sources [Project 2] and understanding simple, common-sense environmental pollution prevention methods [Project 3] are needed. PHEPRO Foundation will conduct these six sub-projects in collaboration with other organizations and corporations to help overcome chronic kidney disease (CKD-mfo) in Sri Lanka. The timeline is given below.

Timeline for Accomplishing the Project:

    All projects will be done in parallel
    Sub-Projects 1–6 mon. 7–12 mon. 13–23 mon. 24–47 mon. 48–119 mon. 120 mon.
  1. White Paper distribution
  2. Water-quality devices

  3. Education of the public

  4. Poverty alleviation

  5. Funding CKD research

  6. Provision of clean water

  7. Outcome statistics

  8. Elimination of CKD-mfo

  9. Socio-economic Payback Resulting From Health Improvement:

    • The provision of clean water together with a region-wide awareness and education campaign would significantly reduce morbidity and premature mortality associated with CKD-mfo, and we eventually will eliminate the occurrence of CKD-mfo in the country and the region.
    • We predict that these benefits will start manifesting within the first two years and continue for years to come. In addition, we envisage that implementation of this project will decrease communicable and non-communicable diseases in the region.
    • The provision of clean water will prevent and reverse the trend of sicknesses (of both humans and animals) and enable farmers to continue of their productive lives.
    • Thus, with the launching of this project, we anticipate major improvement in the national’s productivity and estimate the country will enjoy more than Rs. 2 billion additional income per year.

    Cost-Effectiveness and Savings of Healthcare Costs:

    • The benefits of eliminating CKD-mfo far exceed the mentioned Rs. 2 billion per year; doing so will improve the quality of lives, productivity, the economy, and general prosperity.
    • In the NCP region, approximately 5,000 people die of CDK-mfo each year. With an average of 10% of the population being affected and given the current 5+% CKD-mfo annual death rate, each RO plant would prevent a minimum of five deaths in each village annually.
    • Therefore, over the expected 25-year life span of an RO plant, the provision of clean water via the unit would prevent 125 deaths.
    • Each $64 invested would prevent one death. In addition, there will be major benefits secondary to the reduction of morbidity and relief of the overall disease burden.
    • No medical or other intervention can offer a solution to this region that is as cost-effective in reducing the burden of disease and premature deaths.

    Estimate for Printing and Reverse Osmosis Units:

    The steering committee has diligently worked on obtaining estimates for printing CKD-White Paper and color, laminated educational posters, and a number of quotations for reverse osmosis plants (including potential for solar-power) from companies in United States and from India to obtain best options.

    The Way Forward

    Recently, we have met and discussed this global project with most of the local stakeholders. Particularly with the Minster, the Secretary, Chairman and his staff of the Water Supply and Drainage Board, the Minister of Health and the Director of Health, senior staff of the Department of Agriculture and the Central Environmental Authority, several professors in various local universities and different disciplines, retired senior scientists, and several NGOs. The project has also been presented to President Rajapaksa and Mr. Gotabhya Rajapaksa for their perusal and governmental approvals.

    We have a list of 50 villages that have been determined to be priorities based on the number of patients with and deaths that have occurred secondary to CKD-mfo. However, this is a dynamic list and will be modified as we proceed because the disease is spreading outside the traditional boundaries of the NCP. It is likely that with time, especially in areas such as Padaviya and Medawachchiya, other groups will install smaller-capacity RO units (indeed, some have been installed already). We will not duplicate efforts in such villages. Instead, we will gladly coordinate our efforts with these groups to make the program synergistic. However, to our knowledge no other group is involved in the other five sub-projects we are implementing in this region.

    We Look Forward to Working With You:

    Ecosystems are under unprecedented pressure, threatening prospects for sustainability and the welfare of future generations. Securing the environment is essential for the prosperity of society and the country. We all need to work together to achieve healthy and sustainable goals for the country. The PHEPRO organization will act on its mission for the provision of clean water and protection of the environment and living beings in the areas affected by CKD-mfo. PHEPRO will focus on the activities indicated in the six sub-projects, with the initial goal of reducing disease incidence and the eventual goal of eliminating CKD-mfo from the country.

    We look forward to your productive partnership with a view to undertaking a firm and sustainable plan of action. We sincerely hope your organization will join us in this major philanthropic program and become a champion―an outstanding corporate citizen in saving lives in Sri Lanka.

    PHEPRO Board of Directors

    Treasurer: Mr. Noel Priyathilake (CEO-Fascination Apparel Co.)

    Spokesperson: Mr. Olcott Gunasekera (retired senior civil servant)

    President: Prof. Sunil Wimalawansa (professor of Medicine, Endocrinology & Nutrition)

    Advisory Board:

    Prof. Saroj Jayasinghe [Professor of Medicine]

    Mr. Mahinda Gunasekera [President, SLUNA]

    Mr. Rohan Abeywikrama [CEO-Sathsindhu corp.]

    Prof. Asoka Gunawardena [Professor of Agriculture]

    Dr. Parakrama Wiadyanatha [Rtd. Chairman. Coconut Research Board]

    Mr. Indrajith Samaranayake [Rtd. Engineer]

    Mr. Mahinda Lanarolle [Senior Attorney]

    Mr. Kolitha Gunaratne [HR Specialist]

    Mr. Olcott Gunasekera [retired senior civil servant]

    Mr. Edirisinghe Amithirigala [Director, Mind-Body Institute

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