Structural violence and chronic kidney disease of unknown etiology in Sri Lanka

• Provides a social analysis of Chronic Kidney Disease of unknown etiology (CKDu).
• Explains that CKDu is historically driven and rooted in agricultural policy.
• Shows that CKDu is linked to working conditions of agricultural laborers.
• Uses geospatial, case-control, and ethnographic analyses to CKDu.
• Shows that structural violence explains the social origins of CKDu.

Research published on Chronic Kidney Disease of Unknown Etiology (CKDu) in Sri Lanka has been undertaken largely from biomedical and epidemiological perspectives. The main objective of these studies has been to identify the etiology of the disease, which affects as much as 15–21% of the population in some regions and is associated with kidney failure. Few studies have sought to address how CKDu is socially and behaviorally situated in the affected districts. The present study, informed by structural violence theory, utilized a mixed-method approach that analyzed primary and secondary data for Medawachchiya District Secretariat Division in Anuradhapura District for 2010 and 2015, and examined CKDu as a manifestation of social inequality and exclusion and the creation of a marginalized group of agricultural laborers. Data include historical analyses, a case-control study, ecologic analysis of features of communities and CKDu prevalence, and direct observations and interviews with people in affected communities. In 2010, the most important factor associated with CKDu was private dug wells that were used for supplying water to homes. In 2015, when the number of patients had increased, CKDu was more closely linked to occupation, especially male wage labor. The male wage laborer, being the poorest of the poor, has become a particularly vulnerable social category in agricultural settlements in Medawachchiya. The co-occurrence of this social category and CKDu can be regarded as unintended consequences of the official agricultural colonization policy that started during British colonial times and has continued since independence.