Offline: Breaking the silence in nephrology

Abstract

Durban, 2000. The world's AIDS community came to South Africa despondent about its future. The emerging epidemic in sub-Saharan Africa, combined with President Thabo Mbeki's scepticism about HIV as the cause of AIDS, presented what seemed to be an impossible challenge. I remember an evening with one long-serving WHO Africa-hand who was then advising the agency's Director-General on her AIDS policy. His view was stark, and devastating. There was no future for those living with AIDS in Africa, he said. Treatment could never be provided at scale. The only option, he suggested, was to let those living with HIV die, and hope that prevention efforts would stem the tide of the epidemic for subsequent generations. Then 11-year-old Nkosi Johnson stepped onto the stage at the opening ceremony of the Durban AIDS conference. In front of over 10 000 delegates, he spoke these words: “Care for us and accept us—we are all human beings. We are normal. We have hands. We have feet. We can walk, we can talk, we have needs just like everyone else—don't be afraid of us—we are all the same.” Durban was a turning point in the AIDS epidemic. It was a moment when the consciousness of the AIDS community was awakened to the urgent needs of millions of people like Nkosi Johnson. Simply abandoning those living with AIDS to certain death was no longer acceptable. Nkosi Johnson did die the following year. But his words created the conditions for “3 by 5”—an initiative to get 3 million people onto antiretroviral treatment by 2005. That figure is now 15 million. Cape Town, 2015. The world's nephrology community came to South Africa despondent about its future. Over 85% of people who suffer an episode of acute kidney injury live in low-income and middle-income countries. Around 2·3 million people die every year because of lack of access to treatment for end-stage kidney disease. Some people believe that treating people with renal disease in poor countries is an impossible task. It is better, they say, to let those with end-stage renal disease die, investing the few resources available into prevention. Then Archbishop Desmond Tutu, Nobel Peace Prize winner, stepped onto the stage at the World Congress of Nephrology's opening ceremony last week. With five simple words—“I am because of you”—he stirred the audience into a standing ovation and secured this meeting as a historic turning point in the fight against chronic kidney disease and acute kidney injury. The official theme of the Cape Town meeting was “sustainability and diversity”. Unofficially, it was the powerful idea of achieving zero preventable deaths from acute kidney injury by 2025. The International Society of Nephrology's “0 by 25” initiative is the direct offspring of “3 by 5”. Giuseppe Remuzzi, ISN's President and the stimulus for this transformative vision, asked, “Is the AKI ‘0 by 25’ project overambitious and unrealistic?” “Of course it is”, he said. Which is why we must do it. John Feehally, ISN's former President, showed how the Saving Young Lives in Africa and Asia initiative can provide treatment (acute peritoneal dialysis) to otherwise untreated patients with renal disease, and with a 51% survival rate. The goal, he said, was to reach the point where nobody asks, “Is this the right thing to do?” Feehally set out seven objectives—implementing treatment programmes, capacity building, measuring success, funding, advocacy, partnership, and sustainability. He dismissed those who argued that peritoneal dialysis was a second-rate treatment. He disagreed with those who said it was unaffordable. Instead, the Saving Young Lives programme proved that with local champions and distant mentors a great deal could be achieved against the odds. One obstacle is the word “dialysis”. Like “antiretroviral” in 2000, the notion of dialysis creates panic among politicians anxious about the burden on their national health budgets. But the message to policy makers must be that acute kidney injury is a reversible illness and that treatment is affordable. Would anyone today question the treatment of those diagnosed with malaria or pneumonia? Of course not. Why should acute kidney injury be any different? In 2017, the World Congress of Nephrology meets in Mexico City under the Presidency of Adeera Levin. The challenge to provide services and resources to every woman, child, and man living with life-threatening renal disease, especially the poorest and most vulnerable, is indeed great. The ambition is enormous. But there is no going back now after Cape Town. Signing up for nephrology: the silence is broken in South AfricaIn his Offline (March 21, p 1058),1 Richard Horton wrote about the crisis of chronic kidney disease (CKD) in South Africa, comparing it with the HIV epidemic at the start of the new millennium. He reflected on the sense of helplessness within the local nephrology community. Full-Text PDF