Island of the Widows from The Center for Public Integrity

Thousands of sugar cane workers die as wealthy nations stall on solutions

2013-01-23T14:18:21-05:00

LA ISLA, Nicaragua — Maudiel Martinez is 19 years old and has a shy smile, a tangle of curly black hair and a lean, muscular build shaped by years of work in the sugarcane fields. For most of his adolescence, he was healthy and strong and spent his days chopping tall stalks of cane with his machete.

Now Martinez is suffering from a deadly disease that is devastating his community along with scores of others in Central America, where it has decimated the ranks of sugarcane workers. The same illness killed his father and his grandfather and affects all three of his older brothers.

“This disease eats our kidneys from inside us,” Martinez said. “We don’t want to die, and we feel grief because we already know that we’re hopeless.”

Martinez’ illness stands at the heart of a lethal mystery — and legacy of neglect by industry and governments, including the United States, which have resisted pleas for aggressive action to spotlight the malady and find a remedy. Wealthier nations are more focused on spurring biofuels production in the region’s sugarcane industry and keeping up the heavy flow of sugar to U.S. consumers and food manufacturers than the plight of those who harvest it.

Little noticed by the rest of the world, chronic kidney disease (CKD) is cutting a swath through one of the world’s poorest populations, along a stretch of Central America’s Pacific Coast that spans six countries and nearly 700 miles. Its victims are manual laborers, mostly sugarcane workers.

Each year from 2005 to 2009, kidney failure killed more than 2,800 men in Central America, according to the International Consortium of Investigative Journalists‘ analysis of the latest World Health Organization data. In El Salvador and Nicaragua alone over the last two decades, the number of men dying from kidney disease has risen fivefold. Now more men are dying from the ailment than from HIV/AIDS, diabetes and leukemia combined.

“In the 21st Century, nobody should die of kidney disease,” said Ramon Trabanino, a physician from El Salvador who has studied the epidemic for a decade.

The surge of kidney disease is overwhelming hospitals, depleting health budgets, and leaving a trail of widows and children in rural communities. In El Salvador, CKD is the second leading cause of death for men. In the province of Guanacaste, Costa Rica, the regional hospital had to start a home dialysis program because it was overwhelmed with so many CKD victims that it began running out of beds to treat patients with other ailments.

So many men have died in some parts of rural Nicaragua that Maudiel Martinez’s community, called The Island, now is known as the Island of the Widows — La Isla de las Viudas.

At first glance, the lush community bounded by vast sugarcane fields looks like many places in Latin America: children ride bicycles over dirt roads and play alongside dogs, pigs and chickens. But now there are few men in the front yards. Indoors, framed photographs of dead husbands, fathers and brothers adorn tables and countertops. No older men converge in small groups, trading gossip and news, as one often sees in communities farther inland from the Pacific coast.

Here, women struggle to make at least a little money doing odd jobs. Some are now in the sugar-cane fields they believe claimed their husbands.

“My children have suffered a lot,” said Paula Chevez Ruiz, a widow from La Isla whose husband Virgilio died in 2009, leaving her to support four children on her own. When she can find customers, she sells fruit and enchiladas. “It is sad to want to give to your children, but not to have anything. Sometimes not even enough to buy a bag of salt.”

Deadly enigma and a handful of researchers

In the U.S., leading causes of chronic kidney disease are diabetes and hypertension. But the ailment — leading to a progressive decline in kidney function — is typically a manageable condition that can be effectively controlled with treatment. Doctors understand its causes and cures.

In Central America, the disease’s origins are more of an enigma, and more frequently lethal. Afflicted laborers in the sugar cane fields near the Pacific generally have neither diabetes nor hypertension.

Some scientists suspect that exposure to an unknown toxin, potentially on the job, may trigger onset of the disease. Researchers agree that dehydration and heat stress from strenuous labor are likely contributing factors — and they may even be causing the illness. Laborers, typically paid not by the hour or day but based on the amount they harvest, often work to the point of severe dehydration or collapse, potentially harming their kidneys with each shift.

CKD usually attacks small blood vessels in the kidney called the glomeruli; the Central American epidemic attacks the kidney’s tubules. CKD generally affects older people with equal distribution between sexes; this epidemic overwhelmingly affects working-age men, mostly sugarcane workers but also miners and other agricultural laborers.

A growing community of researchers is calling for recognition of a new illness not yet included in medical manuals: “Mesoamerican nephropathy,” “endemic agricultural nephropathy” or “sugarcane nephropathy.” The director of El Salvador’s national CKD program has written of a “Mesoamerican Regional Nephropathy” that would one day be internationally recognized.

“It is important that the chronic kidney disease afflicting thousands of rural workers in Central America be recognized as what it is: a major epidemic with a tremendous population impact,” said Victor Penchaszadeh, a clinical epidemiologist at Columbia University and frequent consultant to the Pan American Health Organization on chronic diseases in Latin America.

Dr. Ramon Vanegas, a nephrologist who assesses applications by workers to Nicaragua’s Institute of Social Security for occupational illness pensions, said cases which he defines as occupational CKD follow a pattern of tubular kidney damage combined with a history of heat stroke.

“Usually they have been working, and they had muscle spasms, they’ve gotten fever, they have collapsed,” Vanegas said of the patients whose applications he approves. “Then they return to work, they face the same exposures, and the cycle repeats. Then, two or three years later, the patient has [CKD].”

While physicians mull labels and diagnoses, the mystery persists: Why does this particular form of CKD attack men in a particular way — and in this specific region?

Some studies suggest risk factors, from pesticide exposure to alcohol abuse to frequent use of anti-inflammatory drugs, may play important roles in CKD’s onset. Others show that miners, stevedores and field workers in affected regions also have high CKD rates; a study in Nicaragua found a mining town to have one of the highest prevalence rates in the country.

“The evidence points us most strongly to a hypothesis that perhaps heat stress — hard work in a hot climate without sufficient replacement of fluids — might be a cause of this disease,” said Daniel Brooks, lead researcher of a scientific team from Boston University that is among a handful of groups conducting early studies.

During days the team observed sugar cane workers, mean temperature in the fields was 96 degrees. Their report noted that the U.S. Occupational Safety and Health Administration, which oversees safety at U.S. workplaces, calls for 45 minutes of rest for every 15 minutes of work at that heat stress level.

The team’s preliminary research bolsters the heat stress hypothesis; blood and urine samples taken from different types of sugarcane workers during the course of a harvest season show more evidence of kidney damage among those who did strenuous labor outside. Earlier, the team identified a number of work practices and chemicals at the company that could potentially damage the kidneys. Brooks said more research is needed before conclusions can be drawn.

Internal studies by Nicaragua Sugar, owners of one of Central America’s largest sugar plantations, provided by the company to ICIJ, show that the company has long had evidence of an epidemic tied to heat stress and dehydration. In 2001, company doctor Felix Zelaya conducted an internal study on the causes of CKD among its workers. “Strenuous labor with exposure to high environmental temperatures without an adequate hydration program predisposes workers to heat stress syndrome [heat stroke], which is an important factor in the development of CKD,” Zelaya concluded.

Nicaragua Sugar and other companies say they have acted voluntarily to protect workers by improving hydration, reducing work hours, and strengthening oversight of labor contractors.

Even so, Nicaragua Sugar disputes the existence of a unique kidney ailment affecting its workers. “We’re convinced that we have nothing to do with kidney disease,” said spokesman Ariel Granera. “Our productive practices do not generate and are not causal factors for CKD.”

Signs of trouble

In 2000, Salvadoran physician Trabanino noticed large numbers of young and middle-aged men coming into his hospital in El Salvador, all with advanced cases of chronic kidney disease. “For some reason, to the rest of the world this seemed normal,” he recalled. “To me it seemed strange and curious.”

In 2002, Trabanino published one of the first studies of the disease, a profile of 205 new patients admitted to his hospital with end-stage renal disease. Two thirds of these cases lacked the usual risk factors for chronic kidney disease — and had some common features.

“They were almost all men who lived in the low-lying zones of the country, close to the coast, near a major river,” Trabanino wrote in the Pan American Journal of Public Health. A large group of these patients also described “frequent occupational contact without adequate protection with insecticides and pesticides.”

Another study of kidney patients from northern Costa Rica — again from a sweltering, low-lying region near the Pacific Coast — described a similar pattern.

“All are young men, between the ages of 20 and 40 years,” wrote Dr. Manuel Cerdas of Costa Rica in the journal Kidney International. “The most interesting feature of these patients is epidemiologic—all of them are long-term sugar-cane workers.”

Cerdas later found that victims of the epidemic shared another condition: the disease attacked a part of their kidneys called the tubules. Tubulo-interstitial disease is usually rare — accounting for only 3.7 percent of cases of end-stage renal disease in the United States. Known causes include toxic exposure and dehydration.

Today El Salvador promotes blood testing in hard-hit rural areas to try to catch cases in treatable stages. Trabanino, who has studied the epidemic for over a decade, said he believes screening, public education campaigns and improved worker safety could stop the ailment’s spread — if only resources were available.

Researchers in Central America, meanwhile, face an uphill battle. The few CKD studies done so far had been conducted in hospitals and affected communities, where people were already sick. Theories about the role toxic chemicals may play in causing the disease are difficult to test because scientists need access to the epidemic’s victims as they are falling ill.

Silence on CKD; fast action on biofuel

Central American sugar companies have been reluctant to open their doors to outside health researchers. Advocates believe the industry fears designation of the disease as an occupational illness. Resistance has begun to soften — notably at Nicaragua Sugar’s Ingenio San Antonio plantation, where the Boston University team is working. But the industry typically has barred independent scientists from company property, employees or records.

Aurora Aragon, an occupational health specialist at the University of Leon in Nicaragua, said that in 2004 researchers from an international NGO called SALTRA asked Nicaragua’s leading sugar companies to collaborate on a study of worker safety. She said that the Ingenio San Antonio and Ingenio Monte Rosa ignored the request.

In 2007, Aragon said another request for access by her colleagues was rejected by the Ingenio San Antonio. “Ultimately, that was the conclusion,” she said. “Not one sugar company gave us permission to study the problem.”

Mario Amador, a spokesman for the Nicaraguan sugar industry trade group that represents plantations approached by SALTRA, said the industry has allowed studies by doctors, medical students and health authorities, but must exercise caution in sharing information with outsiders.

“People with bad intentions have tried to connect CKD with work in the sugar industry, because this industry was the first to find high rates of CKD in the labor force that came to the plantations seeking work,” Amador said. “It is because of these constant attacks that plantations and their staff are very careful about the information they provide to any person or institution.”

Central American producers play a significant role in the global sugar business; in 2011 the US imported more than 330,000 metric tons of sugar from the region, representing 23% of total raw sugar imports.

Beyond the kitchen table, the U.S. government has heavily promoted the sugar industry — in the areas affected by the epidemic — as a source of biofuel from ethanol. The U.S. funded conferences to promote biofuels in both Nicaragua and El Salvador as late as 2008, according to embassy cables released by WikiLeaks. Its ambassadors met repeatedly with the leaders of both nations’ sugar industries, and fretted that failure to develop ethanol production would drive these nations toward dependence on oil imports from Hugo Chavez’s Venezuela.

In 2007, then-Ambassador Paul Trivelli notified the U.S. State Department of Ingenio San Antonio’s first ethanol shipment and wrote that the company had embraced “the potential to develop the industry and the positive aspects of biofuels.” But he expressed concern that Nicaragua’s leftist president, Daniel Ortega, might be swayed by Venezuelan President Hugo Chavez’s opposition to biofuels.

The following year, Trivelli wrote that the State Department had designated Nicaragua as a “high-priority country” for biofuels. The embassy in El Salvador, Nicaragua’s northern neighbor, also forcefully promoted ethanol: ambassadors met with sugar industry leaders, shared concerns with the State Department about the political effects of oil imports from Venezuela, and sponsored a conference to promote biofuels.

The World Bank, meanwhile, has provided more than $100 million in loans to promote biofuel production at two heavily affected plantations, which it approved without formal consideration of kidney disease. After workers complained, the Bank granted $1 million to sponsor the ongoing Boston University study.

Before receiving the loans, the companies needed to assure the Bank that they lived up to social and environmental standards. Appraisal teams published glowing assessments of the Ingenio San Antonio and Monte Rosa’s practices in September 2006 and May 2007. Neither report mentioned CKD.

In October 2006, the board of the International Finance Corporation (IFC) — the World Bank’s lender for private-sector projects — approved a $55 million loan to Ingenio San Antonio. A $50 million loan to Monte Rosa was approved in June 2007.

With the money, the companies expanded, sending more workers into the cane fields.

Edgar Restrepo, a senior investment officer for the IFC, said his team did consider CKD when it appraised the Ingenio San Antonio, but that the content of its deliberations is privileged. IFC spokeswoman Adriana Gomez said the IFC had “complied with its strict social and environmental standards in the due diligence process.”

A standoff in Mexico City

While governments in Central America have committed few resources to combating CKD, they have begun sounding alarms.

El Salvador’s government has been forceful in calling for international research help. At a United Nations summit of health ministers this February in Mexico City, El Salvador Health Minister Maria Isabel Rodriguez declared that chronic kidney disease was “wasting away our populations” across Central America. She called on fellow health ministers to include CKD among the top chronic illnesses in the Americas, a step that could attract U.N. funding for studies.

Rodriguez’s proposal ran into strong opposition from the summit’s most powerful participant: the United States.

Rodriguez said the U.S. delegation refused either to include the disease on the list of the continent’s most serious chronic illnesses, or to accept language suggesting that the epidemic had distinct causes related to exposure to toxic chemicals.

Central American representatives said they felt so strongly they refused to sign the conference’s final declaration unless CKD was included. For several tense moments, the dispute threatened to derail the consensus of the summit. Result: A single phrase mentioning chronic kidney disease in Central America.

David McQueen, a United States delegate from the Centers for Disease Control and Prevention, told ICIJ that the U.S. opposed mentioning CKD to keep the focus on diabetes, heart disease and cancer.

“Declarations that are made are rarely successful unless they are very targeted,” he said.

McQueen, who has since retired, said he wasn’t aware of the dramatic spread of chronic kidney disease until it was raised at the conference. “The chronic kidney thing sort of caught everybody by surprise,” he said. “Why is this being pushed so hard?” McQueen learned at the meeting that it “is a significant problem,” spurring “a major drain on resources” for physicians and hospitals in Central America.

Yet even after learning of the issue, the U.S. has taken little action. CDC spokeswoman Kathryn Harben said that at a dinner on the night of the Mexico City summit, the CDC informally offered to help Central American health ministries. It has not yet done so, she said, because those ministries have not submitted a formal request. The top U.S. health official at the summit, Dr. Howard K. Koh, assistant secretary for health at the Department of Health and Human Services, declined to be interviewed for this story.

Get sick, lose your job

Ingenio San Antonio and Ingenio Monte Rosa, Nicaragua’s largest plantations, now regularly test workers’ blood to measure creatinine, a chemical that indicates kidney function. Workers with elevated creatinine levels are dismissed, a step the companies say is necessary to prevent sick workers from further risking their health in the fields.

Dismissal also cuts off workers from care at company hospitals, and often from company pensions.

The Ingenio San Antonio said it has reduced work hours, provided more water and hydrating solution and hired social workers to accompany contractors in the fields to ensure adequate hydration. Currently, the workday is no more than eight hours for demanding physical jobs, and the company provides eight liters of water and 2700 milliliters of hydrating solutions daily to each field worker, said spokesman Granera.

In November 2009, Maudiel Martinez boarded a company bus one morning and headed for the fields. He was 17 and starting his fourth year with the Ingenio San Antonio. Harvest season was about to begin and, following routine, the company had conducted blood tests to see if workers were healthy enough for field work.

Martinez was on the bus when he got the news: he’d failed the creatinine test. He had the disease.

“I cried because of my grief,” Martinez said. “I was such a child — at the age of 17 you’re still an adolescent.”

The diagnosis meant that Martinez was formally prohibited from working for the company. With his family struggling financially and no alternative job in sight, Martinez assumed a fake name and Social Security number and went back to work in the same fields, for independent labor contractors who, he said, don’t care that he provides a woman’s name and Social Security number.

At least some contract workers are still going out on longer, riskier shifts. An ICIJ reporter in June 2011 noted that buses picking up Ingenio San Antonio contract workers started at 5:25 a.m. and returned at 5:31 p.m. Workers said about 10 of those hours were spent in the fields.

A collapse in the fields

On June 10, 2011, Martinez was assigned to cut four rows of cane. His task was to strip off the leaves, chop them into pieces, and tie them into bundles. About forty pieces make up a bundle. For this labor, he earned one cordoba per bundle – less than a nickel.

By 8:30 in the morning, he had cut two rows. He was starting to feel sick, but continued to cut in the sweltering heat. “The sun was too strong, and I had sweated through my shirt like someone had thrown water on me,” Martinez recalled.

By the time he finished his rows, at about 11, Martinez was feverish and nauseous. He rested some 15 minutes, but still had to tie his pieces into bundles. Another worker came to help.

Martinez said they finished about 1 p.m., and the bus came to bring the workers home about half an hour later. When it arrived, Martinez felt desperately ill. “I got onto the bus and I couldn’t walk anymore,” he said.

Since Martinez was a contract worker, he could not go to the company hospital. He took the bus toward home and on board began to vomit. The bus did not stop. “The guys gave me a chance to stick my head out the bus window,” he said.

The road where the bus left him is separated from his home by a shallow river. His mother and brother carried him across the river to bring him to his bed.

Soon after his collapse, Martinez learned that his creatinine levels were up. He had gone for days with no appetite, wanting only cold drinks to soothe the sensation of fever.

“If death is coming, we have to resign ourselves to wait for it,” Martinez said. “Resigning yourself means waiting for what the disease is going to give you. Because you look at me and I look normal now, but inside I feel like I’m burning.”

As kidney disease kills thousands across continents, scientists scramble for answers

Sri Lanka — 2012-10-15T15:33:25-04:00

SANDAMALGAMA, Sri Lanka — In this tiny Sri Lankan village, rice farmer Wimal Rajaratna sits cross-legged on a wooden bed, peering out toward lush palm trees that surround his home. Listless and weak, the 46-year old father of two anxiously awaits word on whether his body can accept a kidney donation that offers his only chance of survival.

In Uddanam, India, a reed-thin farmer named Laxmi Narayna prepares for the grueling two-day journey he takes twice every week. For most of his 46 years, his job involved shimmying up palm trees to harvest coconuts at the top. He now spends most of his time negotiating the more than 100-mile bus trips he takes to receive the dialysis treatments that keep him alive.

Ten thousand miles away, in the Nicaraguan community of La Isla, Maudiel Martinez dreads returning to the rolling sugarcane fields where he spent most of his teenage years at work with a machete. Blood tests by the sugar company that employed him found that his kidneys were seriously damaged — and exertion beneath the tropical sun could tip the 20-year-old’s health into a lethal spiral.

In three countries on opposite ends of the world, these men face the same deadly mystery: their kidneys are failing, and no one knows why.

A mysterious form of chronic kidney disease — CKD — is afflicting thousands of people in rural, agricultural communities in Sri Lanka, India and Central America. The struggle to identify its causes is baffling researchers across multiple continents and posing a lethal puzzle worthy of Sherlock Holmes.

The three epidemics have crucial threads in common. The victims are relatively young and mostly farm workers, and few suffer from diabetes and high blood pressure, the usual risk factors for renal disease. They experience a rare form of kidney damage, known as tubulo-interstitial disease, consistent with severe dehydration and toxic poisoning.

Other common links offer clues to a possible cause. The epidemics affect sharply defined geographic areas that are stunningly fertile and swelteringly hot. The victims mostly perform heavy manual labor, have little formal education and lack easy access to medical care. Pesticides are used heavily, and communities drink local groundwater. In each case, the disease began surging in the 1990s.

Despite a decade of research in each affected region — and a potentially noteworthy discovery this year in Sri Lanka — scientists have yet to prove a chemical at fault or a means of exposure. Researchers are convinced that if they could identify the culprit, the outbreaks could be stopped and the death toll reversed.

“I absolutely think that it’s preventable,” said Daniel Brooks, an epidemiologist at Boston University who is leading a study in Nicaragua of the new form of CKD. “I’m very convinced that what is happening to individuals is from some sort of exposure.”

In a sense, researchers are waging a race against three parallel epidemics occurring across multiple continents. Yet the search for clues was slow to begin, with governments including the United States moving with little urgency despite warnings of the disease’s toll. And separate groups of researchers — each chasing clues to kidney epidemics across the globe — have not fully explored whether they are linked together.

The new form of CKD is not officially recognized in the Americas even though kidney disease has killed more people in El Salvador and Nicaragua than diabetes, HIV/AIDS and leukemia combined in the last five years on record, the Center for Public Integrity found.

In a disease not yet formally recognized, researchers cannot say how many have fallen ill. But the death toll reaches tens of thousands.

More than 16,000 men died of kidney failure in Central America from 2005 to 2009, with annual deaths increasing more than threefold since 1990, according to an analysis of World Health Organization data. In Sri Lanka, the WHO says at least 8,000 people suffer from chronic kidney disease of unknown cause, though other sources put the number more than double that. In the Indian state of Andhra Pradesh, more than 1,500 have been treated for the ailment since 2007.

“There’s a need to connect all the dots between these different outbreaks,” said Dr. Ajay Singh, a nephrologist at Harvard Medical School who is leading a study of the epidemic in India. “Our premise should be to first look for common causes.”

The response has been fragmented in part because wealthy countries and international institutions have been reluctant to recognize the problem. Most CKD is caused by diabetes, obesity or hypertension, all fast-growing problems in the developing world. Health officials have sometimes blamed the usual suspects of unhealthy diet and lifestyles for any increase in CKD in poor countries — a diagnosis that neglects the possibility of environmental exposure.

“Nephrologists and public health professionals from wealthy countries are mostly either unfamiliar with the problem or skeptical whether it even exists,” said Dr. Catharina Wesseling, the regional director for the Program on Work and Health (SALTRA) in Central America, which pioneered the initial studies of the region’s unsolved outbreak. “The response from the North and from international agencies must be much stronger.”

In the meantime, thousands of villagers are dying each year from an ailment triggering as many questions as answers. Are tainted agrochemicals to blame? Dehydration in the fields, aggravated by dangerous working conditions? Or could multiple culprits exist, with different causes in each region?

From Sri Lanka to India to Central America, all the victims know is that something in their lush, hauntingly beautiful surroundings is wasting away their lives. In one patch of rural Nicaragua, so many men have died the community is called “The Island of the Widows.” In the Indian region of Uddanam, a reverse trend has taken hold: Couples decline to marry at all.

In Sri Lanka, a Suspect Emerges

Wimal Rajaratna has worked in the rice paddies since he was 20. He enjoyed good health until December 2011, when he began suffering an alarming array of pains. His head pounded, his knees ached at the joints, and his appetite deserted him.

He traveled from his home in Sandamalgama — a village of 27 families — to the doctor in the nearby town of Horowpathana. Tests revealed that his levels of creatinine, a chemical in the blood that indicates kidney function, were an astronomical 9.45 mg/dL — more than seven times higher than normal. He had chronic kidney disease, advanced into its late stages.

Rajaratna’s illness is part of an epidemic sweeping northern Sri Lanka. The disease affects three provinces in the north central region of the country, and estimates of the number of patients range from 8,000 by the World Health Organization to nearly 19,000 in a tally based on hospital records compiled by independent researchers. Prevalence in the affected region is 15 percent, according to unpublished results from a three-year study by the Sri Lankan health ministry and WHO.

The government has even come up with a name for it: CKDu, chronic kidney disease of unknown etiology.

Since 2009, the health ministry and WHO have embarked on the world’s largest and most comprehensive study of CKDu. They have sampled patients’ blood and urine, tested the soil, water and food, and surveyed and mapped the population of the affected region. “We need to do full-blown research on this and then find out the causative agents,” said Dr. Palitha Mahipala, additional secretary of health for Sri Lanka and the leader of the official study.

Still, despite growing public pressure and repeated promises of definitive answers just months away from release, the official program maintained complete silence about its findings for three years.

Finally, in June 2012, the health ministry and WHO publicly identified chemicals they said were an essential cause of the disease. The culprits: The heavy metals cadmium and arsenic, through low-level exposure likely occurring through the food chain. “It’s not a mystery,” said Dr. Shanthi Mendis, the Coordinator and Senior Adviser of the WHO non-communicable disease program and the lead adviser of its efforts in Sri Lanka.

Cadmium and arsenic are both toxins with an array of human health effects that include kidney damage. Cadmium is often present in phosphate-based fertilizers, while arsenic has been detected in several Sri Lankan pesticides and also occurs naturally in some parts of South Asia.

The official findings in Sri Lanka represent a potential breakthrough, with implications in Central America and India. But the scientific program has not yet released any of its data behind its findings — leaving questions unanswered and lingering doubts about its conclusions.

In sufficient quantities, cadmium and arsenic cause the same rare type of kidney damage found in the disease’s victims. However, researchers Mahipala and Mendis said most of their patients’ tests and environmental samples showed these chemicals at levels below the exposure limits set by United Nations agencies.

“It has not exceeded the limits,” Mahipala said. “But now we are just thinking when somebody is exposed to these heavy metals over a long period of time,” damage to the kidney tissue could result.

Mahipala acknowledged that “we can’t really come to a conclusion” about the effects of specific exposures that remain within international limits. Neither he nor Mendis offered evidence to explain how these metals had entered the food chain or the bodies of victims at levels sufficient to cause CKD.

The WHO says it will release official study results in late October that will include hard data. The program is also embarking on research of dietary patterns in the affected region to better understand exposure levels.

Chemicals in Question: Big Business in Sri Lanka

Some evidence suggests that cadmium and arsenic have been disseminated through fertilizers and pesticides, whose import is financed by the Sri Lankan government. So, any definitive link between agrochemicals and public health failings would carry significant consequences.

Sri Lanka’s agrochemical industry disputes the notion that its products are at fault. “We can guarantee that pesticides produced by many multinationals and international companies, they follow all the WHO and FAO [Food and Agriculture Organization] guidelines,” said Rohitha Nanayakkara, secretary of Sri Lanka’s National Agribusiness Council. “We believe that those are not in harmful levels.”

In June 2011, Sri Lanka’s Registrar of Pesticides briefly banned several leading pesticides such as glyphosate and carbofuran after tests found they were contaminated with small amounts of arsenic. A few months later, it reversed the ban after concluding that the arsenic levels were too low to pose a serious threat.

The ban was overturned even as the WHO’s internal meeting notes in June 2011 called for stronger regulation of “nephrotoxic agrochemicals” — and warned that any delay would cause “further accumulation of toxic agents in the environment and result in cumulative damage to the health of the people living in these areas.”

As the fuller details of research remain undisclosed, Sri Lanka’s well-regarded health service struggles to meet the massive need in the affected area. Local doctors say that as few as one of every five patients that need dialysis are approved to receive it. Public hospitals offer kidney transplants if patients can find their own donors and pay a substantial portion of the costs of necessary medications.

In Rajaratna’s case, a friend of his family has offered to donate a kidney. As Rajaratna awaits the result of blood tests to determine if he is a match, he travels more than 60 miles twice a week to get dialysis, sleeping on the concrete floor of the hospital when his treatment goes too late for him to take the last bus home. He has no idea how he became so sick.

“That’s what I need to know,” he said. “What happened to me?”

In India, the Trouble in Uddanam

Laxmi Narayna’s village, Gonaputtuga, is part of a verdant rural belt along India’s eastern coast called Uddanam. Spanning less than 100 miles, this stretch of villages near the northern border of the Andhra Pradesh state has been suffering for two decades from a mysterious strain of CKD.

Healthy throughout his 46 years, Narayna began experiencing a painful series of ailments in late 2011. His body began to swell, he had difficulty urinating and he found blood in his stool. He visited a doctor in the closest major city, Visakhapatnam, where he learned he had CKD.

Unable to work after decades spent harvesting coconuts from the top of palm trees, Narayna spends his days resting and traveling back and forth from dialysis in Visakhapatnam. “Now, I do nothing,” he said. “I take medicines and be.”

India’s wave of CKD is smaller than the other outbreaks — but highly concentrated. Unpublished results from a study by Harvard Medical School found that 37% of the population in the hardest hit village, Akkupalli, had the disease. From 2007 to 2012, 1,520 patients from Uddanam received care for CKD from a state health insurance program for the poor. But this number significantly understates the burden of a disease that is latent until it reaches its advanced, deadly stages.

Unlike Sri Lanka and Central America, the illness affects men and women roughly equally, according to separate findings by researchers from Harvard and Stony Brook University. The gender equality and geographic concentration of the illness have focused concentration on potential contamination, particularly in the drinking water.

“This seemed to be an exposure to the community as a whole,” said Singh, of Harvard. Dr. Ravi Raju Tatapudi, a leading nephrologist in Andhra Pradesh and the other study director, said heavy metals and pesticides running off from the fields into the groundwater were the group’s primary suspects.

Despite years of attention to the disease, not one study has been published about Uddanam CKD. The Harvard group has conducted extensive tests of the groundwater and soil in the area, but the results have been delayed for months at a laboratory in Hyderabad.

For Laxmi Narayna, time is running out. At the Seven Hills Hospital, he smiles bravely and says he feels no pain, but his thin frame is dwarfed by the wide cot he rests on and the hulking hemodialysis machine attached by tubes to his arm.

“On dialysis people don’t do well,” said Narayna’s doctor, Ravi Shankar Machiraju. “Holding on for a year would be just about it.”

In Central America, the Science of Sweat

Maudiel Martinez started working in the cane fields at 14. His father had died of CKD two years before, and his family was struggling. After three years of work at the Ingenio San Antonio plantation, he was diagnosed with CKD at 17.

He continued to work — providing false identification to contractors who looked past the fact that his permit carried a woman’s name.

The epidemic in Central America spans six countries along a nearly 700-mile stretch of the Pacific coast. Across the region, kidney failure has killed more than 2,800 men each year from 2005 to 2009, according to an analysis of data from the WHO. In El Salvador, the kidney disease has become the second leading cause of death among adult men.

Groups of sick workers picket the gates of powerful sugar companies, demanding that the ailment be compensated as an occupational illness.

The Ingenio San Antonio sugar plantation is the epicenter of the fight. There, workers have been protesting for nearly a decade, alleging that the company’s pesticides and labor practices caused the disease. After the World Bank provided the Ingenio San Antonio with a $55 million loan in 2006, workers complained to the Bank’s ombudsman — leading to an agreement that the company fund the ongoing Boston University study.

The BU team has pinpointed evidence suggesting that heat stress and dehydration are key contributing factors. Workers who performed strenuous labor in the sun, such as cane cutters, suffered significantly more kidney damage over the course of a single harvest season than those with less arduous job responsibilities, the researchers found.

However, recent tests of adolescents found that many had markers of kidney damage without ever having entered the fields — suggesting a pre-existing exposure as well.

Brooks, the leader of the Boston University team, hypothesizes that a toxic exposure may render the population vulnerable but is not enough to trigger the disease by itself. “It doesn’t actually go to chronic kidney disease until you get what I would call the second hit, which would be the strenuous labor and the dehydration that may come from this difficult work,” he said.

Researchers in El Salvador have also uncovered intriguing clues. A study published in April found that low-lying, coastal communities that grew sugarcane and cotton were both swamped by the disease, while a sugarcane community at a higher altitude was barely affected — illustrating the vital role of geography. In Costa Rica, the government has launched a study that will seek to officially determine whether the illness is an occupational disease.

Workers like Martinez continue to place themselves at risk to support their families. At 20 years old, he is recently married and his wife is expecting a baby. “I feel like every day I work I’m taking away a little part of my life,” Martinez said.

“We work there because the company is the only option we have.”

Missed Opportunities

As the economic and human costs mount, governments have begun to fund studies and treatment programs. El Salvador has launched an initiative called NefroLempa that targets chronic kidney disease, the state of Andhra Pradesh has created a health insurance system for the poor and built new dialysis facilities, and Sri Lanka has worked closely with the WHO on research.

But international institutions and wealthy nations have repeatedly failed to connect the dots, let alone invest on a scale some experts say is necessary.

At a 2011 health summit in Mexico City, the United States beat back a proposal by Central American nations that would have listed CKD as a top priority for the Americas and adopted an official consensus that the Central American epidemic had distinct causes from most CKD.

“The idea was that to keep the focus on the key big risk factors that we could control and the major causes of death: heart disease, cancer and diabetes,” said David McQueen, a U.S. delegate from the Centers for Disease Control and Prevention who has since retired from the agency. “And we felt, the position we were taking, that CKD was included.”

McQueen’s comments reflect the widely held view that any CKD in developing countries stems from diabetes and other diet-related risk factors rather than a new form of illness.

For its part, the WHO has not made any connections between the studies it is supporting in El Salvador and in Sri Lanka. In Central America, it has neither adopted a formal name for the disease nor considered whether it is related to the illness that it recognizes as “CKDu” in Sri Lanka.

The WHO has not kept a record of outbreaks similar to CKDu — there have also been comparable reports in Egypt — and believes that it is premature to extrapolate findings from Sri Lanka onto other regions.

CKD researchers are beginning to study each other’s work independently. Scientists from Boston University, the Central American NGO SALTRA, and Sri Lanka have shared notes, and many will convene at a SALTRA-organized conference in Costa Rica in November. “We definitely need to see this as a global epidemic, but we must not forget that there may be important local causes and drivers,” said Wesseling, the SALTRA director in Central America.

But so far, none of the scientists have systematically compared the epidemics or joined forces across regions to explore the broader phenomenon. The teams from Harvard and Boston University, based half an hour apart, have never met.

The medical mystery is so difficult to solve in part because the pieces do not fit together easily. It is possible that each epidemic has a different cause: pesticides in one place, hard labor in another and an unexamined risk factor such as genetics in the third.

Yet most on-the-ground researchers believe they are connected.

“We’re talking about these outbreaks that are happening among poor agrarian residents of these countries, mainly among men … and that do not seem to be explained by diabetes or hypertension or any of the typical risk factors,” said Boston University’s Brooks. “So those things lead me to really think there’s a good chance they are in fact connected.”

Support our new investigation into a deadly disease killing agricultural workers

2012-09-14T10:28:04-04:00

Editor’s note — 4/16/12: In the past 24 hours, our Kickstarter project has officially exceeded our goal of $7,500. Many thanks to everyone who pledged their support. We'll have more details on the investigation's next steps soon.

A deadly disease is killing thousands of the world's poorest laborers — and no one knows what is causing it. Last December, reporter Sasha Chavkin and the Center for Public Integrity published an investigation about this deadly mystery, chronic kidney disease.

In the United States, chronic kidney disease is a manageable illness that mostly affects older people with diabetes and high blood pressure. But in Central America, each year thousands of agricultural laborers — almost all men, lacking the usual risk factors, and as young as their 20s — are dying of a new strain of chronic kidney disease that has baffled scientists for more than a decade. The disease has so decimated one community of sugarcane workers in Nicaragua called La Isla, or The Island, that it is now known to locals is La Isla de las Viudas — The Island of the Widows.

That first story about the epidemic prompted the Costa Rican government to launch a study and a leading Costa Rica plantation to announce an overhaul of its worker safety practices. Photographer Anna Maria Barry-Jester produced an award-winning photo gallery on the Island of the Widows that shows the day-to-day routines of a community where an incredible 40 percent of the working-age population suffers from the disease.

But new evidence suggests that this mysterious new form of CKD is not a regional anomaly but an international phenomenon. Sasha and Anna are working on a new investigation that will be the first to connect the outbreaks that are killing some of the world’s poorest and most marginalized workers in Central America to other parts of the world — across several continents.

Now, we're asking for you to support this team to travel and report, for the first time, on the epidemic’s scope, and expose the risky working conditions and international neglect that have enabled the ailment to become a public health crisis to another part of the world. Sasha plans to write a series of articles exploring this new international threat, and Anna will produce a photo gallery and video illustrating its human consequences. Each year this deadly epidemic is killing thousands of the world's poorest citizens — please help make the world take notice by going to KickStarter and pledging your support for this work.

Costa Rica to study kidney disease afflicting sugarcane workers

Costa Rica — 2012-02-14T18:31:07-05:00

The Costa Rican government has launched a study into the causes of chronic kidney disease in its sugarcane producing northern region. At the same time one of the country’s biggest sugar producers said it is revamping its worker health and safety policies.

The steps follow an investigation by the International Consortium of Investigative Journalists that explored the mysterious and largely overlooked epidemic of chronic kidney disease — or CKD — that is killing thousands of sugarcane workers and other manual laborers in Central America.

The Costa Rica study will seek to answer one of the thorniest and most politically sensitive questions surrounding what regional health experts call an epidemic: whether the illness should be classified as an occupational disease. Many workers believe the malady is caused by pesticide exposure and working conditions. They have demanded compensation from the sugar industry, which has vehemently denied responsibility.

“The main objective is to test whether CKD is or is not a labor-related exposure,” said Dr. Roy Wong, an epidemiologist with Costa Rica’s national health service and lead investigator for the study.

The cause of the disease’s outbreak remains unknown, although a growing body of research has shown links between declining kidney function and repeated heat stress and dehydration — the result of strenuous labor in hot climates.

The Costa Rican study will survey some 800 people -- mostly men -- in selected from eight of the hardest hit towns and villages in the country’s northernmost province, Guanacaste. This sampling will include both a group that has CKD and a group that does not. Researchers will compare their answers to a survey that measures their exposure to various risk factors. The factors being tested include pesticide exposure, heat stress, overuse of pain medication, and consumption of home-brewed and potentially tainted alcohol known as guaro.

A later phase may include environmental tests of soil and drinking water, depending on the results of the survey, Wong said.

This official investigation could have major implications for worker safety if it finds that the disease is linked to sugarcane work, said Dr. Manuel Cerdas, a nephrologist at Costa Rica’s Hospital Mexico who has studied the epidemic in Guanacaste.

“If it proves this, the government will say to the managers of sugar plantations that they have to consider their work hours, the temperatures, improve their hydration,” said Cerdas, who will participate in the study.

One major Costa Rican plantation, the Ingenio El Viejo, isn’t waiting for the government study. Days after ICIJ’s investigation was published in Costa Rica’s La Nacion newspaper, the plantation adopted a policy of supplying cane workers with a hydrating solution. The company has also started working with doctors from the national health service to develop a complete plan to keep CKD from afflicting its fulltime workers, and provide workers with access to CKD screening.

“This is the first step we’re taking to improve the conditions of hydration for the cane cutters,” said Jose Miguel Obando, risk prevention director at Ingenio El Viejo. “Our intention is for the cane cutter to find good conditions during the four months of the harvest that he is here.”

El Viejo's reforms were welcomed by advocates, who said the steps can save lives. But they emphasized a need to rigorously monitor workers. It is crucial to make sure that cane cutters are properly hydrated throughout their shifts – that they’re actually drinking the solution — said Jennifer Crowe, a researcher with SALTRA, a network of Central American scientists that has played a pioneering role in the study of the epidemic.

In Guanacaste, doctors who last year described being overwhelmed by the flood of CKD cases said they are optimistic that the Costa Rica study might yield additional resources to treat patients.

"There are many things we still lack, but I think the investigation with institutional support is a key point in order to know our needs," said Dr. Monica Espinoza, director of the CKD outreach program at Hospital de Liberia in Guanacaste. "It is a great help because from there we can work on risk prevention."

A broader response to the CKD epidemic would likely require international support. Yet developed nations including the United States have so far declined to actively investigate the outbreak. In February 2011, the United States helped defeat a proposal by El Salvador and other Central American nations to include CKD in an initiative by the World Health Organization and United Nations to battle chronic diseases in the Americas.

Even as those nations press for answers, and Costa Rica launches a study, the Centers for Disease Control has yet to take an active role or recognize Central America’s CKD epidemic. A CDC spokeswoman said she is “not aware of any new developments” involving the deadly disease.

Center for Public Integrity Senior Writer Ronnie Greene contributed to this report.

About this project

Salvador,Bahia,Brazil — 2012-01-06T14:12:50-05:00

Thousands of men working in the Pacific Coast sugarcane fields of El Salvador, Nicaragua, Costa Rica and neighboring countries have been dying of chronic kidney disease, an ailment that in most parts of the developed world is a manageable condition. The condition has been exacerbated by difficult working conditions and poor access to timely health care, while Central American governments and the sugar industry have done little in response.

Over the years the number of cases of CKD has grown — so much that one community near sugarcane fields in Nicaragua, called La Isla, or The Island, is now known locally as the Island of the Widows. From 2005 to 2009, CKD claimed more than 2,800 men each year in the region; in El Salvador it is now the second-leading cause of death among adult men.

This was the phenomenon — widespread illness and death among a specific group of mostly men — that journalist Sasha Chavkin saw on a number of trips to the region over the past two years. Chavkin returned to the region on behalf of the International Consortium of Investigative Journalists, a project of the Center for Public Integrity, to interview dozens of current and former sugarcane field workers and their families and physicians, as well as researchers in the region. Reporting from Washington, D.C., Ronnie Greene, a senior reporter at the Center, joined Chavkin in pursuing answers and data from government health officials in a position to push for more action on CKD, global health officials and sugar industry representatives.

The reporters wanted to know: Why does it strike mostly men who mostly work in sugarcane fields? What triggers it? Why are so many people dying? What have wealthier nations and NGOs done to help?

After five months of reporting, Chavkin and Greene wrote this account about the victims, the inaction among those who should act, and of the lingering mysteries around why CKD is so lethal among certain sugarcane workers in Central America.

More victims and government officials were interviewed by Journalist Kate Sheehy for Public Radio International’s The World. Sheehy is based in the El Salvador offices of El Faro, an investigative website edited by Carlos Dada, a member of the International Consortium of Investigative Journalists, a network of 115 journalists in 51 nations. ICIJ members Carlos Fernando Chamorro in Nicaragua and Giannia Segnini in Costa Rica also contributed reporting to this project.

Questions? Comments? Let us know.

The Team:

Lead reporters: Sasha Chavkin and Ronnie Greene

Sasha Chavkin is a reporter at The New York World, an online publication that conducts investigative reporting on New York City government. He previously wrote for ProPublica, where his reporting on disabled borrowers with student loans, BP oil spill damage claims and BP cleanup workers helped prompt changes in federal and private programs. He has also reported abroad from Nigeria, Bolivia and Peru.

Ronnie Greene joined the Center after serving as investigations and government editor for The Miami Herald. He also spent nine years at the paper exposing slave-like conditions in Florida’s farm fields, investigating deadly air cargo plane crashes and uncovering corruption at Miami’s airport. Greene is author of Night Fire: Big Oil, Poison Air, And Margie Richard’s Fight To Save Her Town, and his work has been honored by the Gerald Loeb Awards, National Press Club, Investigative Reporters and Editors and National Headliner Awards.

Radio reporter: Kate Sheehy (Public Radio International’s The World)

Web team: Ajani Winston, Sarah Whitmire

CPI Web editor: Christine Montgomery

CPI data editor: David Donald

The World editor: David Baron

Translator: Matías Godoy

Publishing partners:

PRI’s The World (radio)

BBC World Service (radio)

Univision (television)

El Nuevo Herald, Miami

La Nacion, Costa Rica

El Faro, El Salvador

Semana, Nicaragua

Hoy, Chicago

Al Dia, Dallas

La Opinion, Los Angeles

Project editors: Ricardo Sandoval Palos (ICIJ) and Keith Epstein (CPI)

Methodology

Salvador,Bahia,Brazil — 2011-12-12T11:09:25-05:00

Our analysis of the toll from chronic kidney disease (CKD) in Central America is based on mortality data from the World Health Organization. Our goal was to obtain to a conservative estimate of the epidemic’s impact in the region, despite the lack of formal recognition or classification for the new strain of the disease.

We used data for each of the countries where scientific studies and our interviews and observations indicated the ailment was present: Nicaragua, El Salvador, Costa Rica and Guatemala. Studies have indicated the disease is spreading in Honduras and Mexico as well. No data were available for Honduras, and while one study has shown CKD to be present in two communities in southern Mexico, there was no way of isolating the relatively small region that is affected.

Our statistics are drawn from several diagnostic categories from the International Classifications of Disease (ICD-10) that indicate kidney failure. This is partly because the lack of a distinct category for the epidemic resulted in kidney disease deaths being classified in different ways. It is also because prior to 2000, the World Health Organization presented data in only a single category that indicated overall deaths caused by kidney failure. To track changes over time and maintain a consistent approach, we applied the same formula to the newer data.

Two WHO doctors, Dr. Enrique Perez-Flores and Dr. Mario Melendez Montano, helped shape our analysis of these data. Both emphasized the degree to which it was likely to undercount the data due to poor recordkeeping and lack of recognition of CKD in the region. Perez-Flores agreed that changes in male deaths from kidney failure over time were a reasonable method for tracking the epidemic’s course in the absence of official recognition for it.

The data show that this formula clearly reflects the CKD epidemic. Across Central America in 2009, the most recent year available, 87 percent of male deaths from kidney failure fell within the signature diagnoses of the epidemic, “Chronic Kidney Disease” and “Unspecified Kidney Failure.” Moreover, the recent increase in CKD is reflected entirely within these categories. Across the region in 2000 (excluding Guatemala, where data was not yet available), there were 157 deaths caused by kidney failure that did not fall within the signature CKD categories. In 2009, there were 161 such deaths.

In other words, kidney failure deaths not caused by CKD appear flat in the last decade, while those caused by CKD skyrocketed.

Also, WHO data show that while kidney disease grew among women in the four Central American countries used for analysis, the rate of growth was smaller among women than men. CKD affects mostly men.

We also considered the possibility that the growing numbers of CKD deaths reflected a secular rise in the disease not connected to the epidemic. CKD is a growing public health threat worldwide, and an increase in traditional forms of CKD likely accounts for some of the increased mortality. In the United States, overall deaths of dialysis patients increased 175% from 1990 to 2009, according to statistics from the U.S. Renal Data System. But even this increase pales compared to men in Central America. In El Salvador and Nicaragua, the countries where data is complete from 1990 to 2009, male death rates from kidney failure increased 458% over the same period.

Finally, it is important to consider the circumstances that these records reflect. Victims of the epidemic are impoverished sugarcane workers and manual laborers in rural areas of Central America. Recordkeeping in these regions is poor, and many die without a death certificate being filed or a cause of death being recorded. Dr. Mario Melendez Montano, who works in El Salvador, said that a significant proportion of CKD deaths are never recorded at all. For this reason, we believe that our findings likely represent a significant undercount of the epidemic’s death toll in the region.

SLIDESHOW: A legacy of neglect

2013-01-23T11:19:01-05:00

See the families afflicted by a mysterious kidney disease that has killed 2,800 men in an isolated region of Central America

Miles de trabajadores de caña de azúcar mueren ante escasez de acción oficial

Salvador,Bahia,Brazil — 2012-02-24T10:55:55-05:00

You can also read this story in English.

LA ISLA, Nicaragua —Maudiel Martínez tiene 19 años, una sonrisa tímida, una maraña de rulos negros y un cuerpo delgado y muscular formado en años de trabajo en campos de caña de azúcar. Durante la mayor parte de su adolescencia fue fuerte y saludable; pasaba los días talando con su machete las altas cañas.

Hoy Martínez sufre de una enfermedad letal que está devastando a su comunidad y a muchas otras en Centroamérica, donde ha diezmado legiones de cañeros. La misma enfermedad mató a su padre y a su abuelo y afecta a tres de sus hermanos mayores.

“Esta enfermedad nos come los riñones desde adentro –dijo Martínez–. No queremos morir, y estamos tristes porque ya sabemos que no tenemos esperanza.”

La enfermedad de Martínez compone el núcleo de un secreto letal –y de una tradición de desinterés y descuido por parte de la industria y los gobiernos, incluido el de los Estados Unidos, que han rechazado pedidos de actuar con energía para hacer conocer la enfermedad y encontrar una cura. Los estados ricos están más interesados en alentar la producción de biocombustibles en la industria azucarera de la región y en mantener el abundante flujo de azúcar hacia los consumidores y productores de alimentos de los Estados Unidos que en ocuparse de los problemas de los que la cultivan.

Poco conocida en el resto del mundo, la enfermedad renal crónica (ERC) está causando estragos en una de las poblaciones más pobres del mundo, a lo largo de una franja de la costa Pacífica de Centroamérica que abarca seis países y cerca de 1.130 kilómetros. Sus víctimas son trabajadores manuales, en su mayoría cañeros.

Entre 2005 y 2009, la enfermedad renal mató a más de 2.800 hombres por año en Centroamérica, según el análisis de los datos de la Organización Mundial de la Salud realizado por el Consorcio Internacional de Periodistas de Investigación (ICIJ, por sus siglas en inglés). Solo en El Salvador y Nicaragua, en las últimas dos décadas el número de hombres que murieron de enfermedad renal se quintuplicó. Hoy mueren más hombres de esta enfermedad que los de VIH/SIDA, diabetes y leucemia sumados.

“En el siglo 21, nadie debería morir de enfermedad renal”, dijo Ramón Trabanino, médico de El Salvador que ha estudiado la epidemia durante una década.

La oleada de casos de enfermedad renal está superando la capacidad de los hospitales, agotando los presupuestos de salud y dejando una estela de viudas y niños en las comunidades rurales. En el Salvador, la ERC es la segunda causa de muerte entre los hombres. En la provincia de Guanacaste, Costa Rica, el hospital regional tuvo que desarrollar un programa de diálisis domiciliaria porque estaba tan sobrepoblado de enfermos de ERC que empezó a quedarse sin camas disponibles para las víctimas de otras dolencias.

Tantos hombres han muerto en algunas regiones rurales de Nicaragua que la comunidad de Maudiel Martínez, llamada La Isla, se conoce ahora como La Isla de las Viudas.

A primera vista, esa comunidad de vegetación exhuberante rodeada de vastos cultivos de caña se parece a muchas otras de América Latina: los niños andan en bicicleta por caminos de tierra o juegan con los perros, los cerdos y las gallinas. Pero hay pocos hombres en los jardines de las casas. Adentro de ellas, las fotos de esposos, padres y hermanos muertos adornan mesas y muebles. No se arman corrillos de viejos comentando los chismes y las noticias, como suele verse en las comunidades más alejadas de la costa Pacífica.

Aquí, las mujeres se esfuerzan mucho para ganar poco con trabajos ocasionales. Algunas trabajan en los campos de caña que, están convencidas, se llevaron a sus maridos.

“Mis hijos han sufrido mucho”, dijo Paula Chávez Ruíz, una viuda de La Isla cuyo marido, Virgilio, murió en 2009, dejándola a cargo de sus cuatro hijos. Cuando encuentra clientes, vende fruta y enchiladas. “Es triste querer darle de comer a tus hijos, y no tener nada. A veces ni siquiera para comprar una bolsa de sal.”

Un enigma letal y un puñado de investigadores

En los Estados Unidos, las causas principales de enfermedad renal crónica son la diabetes y la hipertensión. Pero la enfermedad, que deriva en un progresivo deterioro de las funciones renales, suele ser un mal manejable, que se puede controlar con tratamiento. Los médicos comprenden sus causas y su cura.

En Centroamérica, los orígenes de la enfermedad son más enigmáticos y frecuentemente más letales. Los trabajadores afectados en los campos de caña de azúcar cerca del Pacífico no suelen padecer diabetes ni hipertensión.

Algunos científicos sospechan que el contacto con alguna toxina desconocida, probablemente durante la jornada de trabajo, puede ser el detonante de la enfermedad. Los investigadores concuerdan en que la deshidratación y la insolación producto de las arduas jornadas laborales son factores probables, e incluso pueden ser la causa de la enfermedad. Los trabajadores, a quienes se les paga no por cantidad de horas o días trabajados sino por cantidad recogida, suelen trabajar hasta el extremo de la deshidratación y el desmayo, dañando potencialmente sus riñones en cada turno.

Usualmente, la ERC ataca unos pequeños vasos sanguíneos del riñón llamados glomérulos; en cambio, la epidemia Centroamericana ataca los túbulos del riñón. La ERC afecta por lo general a adultos mayores, hombres y mujeres con idéntica frecuencia; esta epidemia afecta mayormente a los hombres en edad laboral, especialmente a los cañeros pero también a mineros y otros trabajadores agrícolas.

Una creciente comunidad de investigadores está pidiendo el reconocimiento de una nueva enfermedad aún no incluida en los manuales médicos: “nefropatía mesoamericana”, “nefropatía agrícola endémica”, o “nefropatía azucarera”. El director del programa nacional de ERC de El Salvador ha escrito acerca de una “nefropatía regional mesoamericana” que algún día llegaría a ser reconocida mundialmente.

“Es importante que la enfermedad renal crónica que afecta a miles de trabajadores rurales en Centroamérica sea reconocida por lo que es: una gran epidemia con un impacto tremendo sobre la población”, dijo Víctor Penchaszadeh, epidemiólogo clínico de la Universidad de Columbia y frecuente consultor de la Organización Panamericana de la Salud (PAHO) sobre enfermedades crónicas en América Latina.

El doctor Ramón Vanegas, nefrólogo encargado de estudiar las aplicaciones para pensiones por enfermedades ocupacionales presentadas por los trabajadores al Instituto de Seguridad Social de Nicaragua, sostiene que los casos que él califica como ERC ocupacional siguen un patrón de lesión de los túbulos renales combinados con antecedentes de insolación.

“Usualmente han estado trabajado y han tenido espasmos musculares, han sufrido fiebres y se han desmayado”, dijo Venegas acerca de los pacientes cuyas aplicaciones ha aprobado. “Entonces regresan al trabajo, se exponen a los mismos síntomas, y el ciclo se repite. Dos o tres años después, el paciente contrae ERC.”

Mientras los médicos ponderan etiquetas y diagnósticos, el misterio persiste: ¿por qué esta forma particular del ERC ataca a los hombres de un modo singular y en esta región específica?

Algunos estudios sugieren que factores de riesgo, desde el contacto con pesticidas al abuso del alcohol, pasando por el uso frecuente de drogas antiinflamatorias, pueden jugar un papel importante en la aparición del ERC. Otros muestran que mineros, estibadores y trabajadores de cultivos en regiones afectadas también presentan altas tasas de ERC; un estudio en Nicaragua encontró un poblado minero que tenía una de las tasas más altas del país.

“La evidencia decididamente favorece la hipótesis de que el agotamiento debido al calor –trabajo pesado en un clima caliente sin la necesaria reposición de fluidos– puede ser una de las causas de esta enfermedad”, dijo Daniel Brooks, investigador principal en un equipo de científicos de la Universidad de Boston, uno de los pocos que están llevando a cabo estudios tempranos.

Durante días el equipo observó a cañeros; la temperatura media en los campos era de 35,5 grados. En su reporte, anotaron que la Administración de Seguridad y Salud Ocupacionales (OSHA) de los Estados Unidos, encargada de velar por la seguridad en los lugares de trabajo, exige 45 minutos de descanso por cada 15 minutos de trabajo bajo esos niveles de calor.

La investigación preliminar del equipo refuerza la hipótesis del agotamiento debido al calor; las muestras de orina y sangre de diversos tipos de cañeros durante una temporada de recolección evidencian la presencia de daños renales entre los que trabajaron al aire libre. Antes, el equipo ya había identificado una cantidad de prácticas y químicos en la compañía que eran una potencial amenaza para los riñones. Brooks dijo que se necesitan ulteriores investigaciones antes de sacar alguna conclusión.

Estudios internos hechos por la Nicaragua Sugar, dueña de uno de los cultivos de caña más grandes de Centroamérica, facilitado a ICIJ por la misma compañía, muestran que se ha tenido evidencia de una epidemia conectada con la insolación y la deshidratación por mucho tiempo. En 2001, el médico de la compañía Félix Zelaya llevó a cabo un estudio interno sobre las causas de ERC en sus trabajadores.

“Trabajo extenuante con exposición a temperaturas ambientales altas sin un programa de hidratación adecuado predisponen al sindrome de fatiga por calor (insolación) que es un factor important en el desarrollo de ERC”, concluyó Zelaya.

La Nicaragua Sugar y otras compañías afirman que han actuado voluntariamente para proteger a los trabajadores, mejorando su hidratación, reduciendo las horas de trabajo y reforzando el control sobre los contratistas laborales.

Aún así, Nicaragua Sugar disputa la existencia de una única enfermedad renal que afecta a sus trabajadores. “Estamos convencidos de que no tenemos nada que ver con la enfermedad renal”, dijo el vocero Ariel Granera. “Nuestras prácticas productivas no generan y no son factores causantes de la ERC”.

Indicios de problemas

En el año 2000, el médico salvadoreño Trabanino notó que una gran cantidad de trabajadores jóvenes y de edad mediana llegaban a su hospital en El Salvador, todos con casos avanzados de ERC. “Por algún motivo esto le parece normal al resto del mund, dijo. “A mí me parece extraño e intrigante”.

En el 2002, Trabanino publicó uno de los primeros estudios sobre la enfermedad, un perfil de 205 pacientes admitidos en su hospital con enfermedad renal terminal. Dos tercios de esos casos carecían de los factores de riesgo comunes a la ERC, y compartían algunas características.

“Casi todos eran hombres que vivían en las zonas más bajas del país, cerca de la costa, cerca de algún río importante”, escribió Trabanino en el PanAmerican Journal of Public Health. Gran parte de los pacientes también habían estado sometidos a “contacto ocupacional frecuente con insecticidas y pesticidas sin la protección adecuada”.

Otro estudio sobre pacientes con enfermedad renal del norte de Costa Rica –de nuevo provenientes de una región baja y sofocante cercana a la costa Pacífica– mostró un patrón similar. “Todos son hombres jóvenes, entre los 20 y los 40 años de edad”, escribió el doctor Manuel Cerdas, de Costa Rica, en la revista Kidney International. “La característica más interesante de estos pacientes es epidemiológica: todos llevan años trabajando como cañeros.”

Más tarde, Cerdas descubrió que las víctimas de la epidemia compartían otra condición: la enfermedad atacaba los túbulos de sus riñones. La enfermedad túbulo-intersticial es rara, culpable tan solo del 3,7% de los casos de enfermedad renal terminal en los Estados Unidos. Las causas conocidos incluyen exposición a toxinas y deshidratación.

Hoy, El Salvador promueve pruebas de sangre en las zonas más afectadas para tratar de encontrar casos en etapas aún tratables. Trabanino, que ha estudiado la epidemia por más de una década, cree que los chequeos, las campañas de educación pública y el mejoramiento de la seguridad laboral podrían detener la expansión de la enfermedad, si tan solo hubiera recursos disponibles.

Mientras tanto, los investigadores de Centroamérica libran una difícil batalla. Los escasos estudios sobre ERC existentes han sido llevados a cabo únicamente en hospitales y comunidades afectadas donde la gente ya estaba enferma. Las teorías sobre el probable rol de químicos tóxicos en la aparición de la enfermedad son difíciles de probar, ya que los científicos necesitan tener acceso a las víctimas de la epidemia cuando se están empezando a enfermar.

Silencio alrededor de la ERC; rápida acción en biocombustibles

Las compañías de azúcar centroamericanas han sido reacias a abrir sus puertas a los investigadores de salud externos. Sus defensores creen que las industrias temen que la enfermedad se catalogue como de tipo ocupacional. La resistencia ha empezado a ceder, particularmente en el Ingenio San Antonio de la Nicaragua Sugar, donde trabaja el equipo de la Universidad de Boston. Pero por lo general la industria le ha negado a científicos independientes el acceso a sus propiedades, empleados y registros.

Aurora Aragón, especialista en salud ocupacional de la Universidad de León en Nicaragua, afirmó que en 2004 los investigadores de una ONG internacional llamada SALTRA le pidieron a las principales compañías azucareras colaborar con un estudio sobre la seguridad de los trabajadores. El Ingenio San Antonio y el Ingenio Monte Rosa ignoraron la petición.

Y en 2007, dijo Aragón, otra petición de acceso fue rechazada por el Ingenio San Antonio. “Y ese fue el fin del asunto— dijo—. Ni una sola compañía azucarera nos dio permiso para estudiar el problema.”

Mario Amador, vocero del gremio industrial nicaragüense que representa las plantaciones contactadas por SALTRA, dijo que la industria ha aceptado estudios de médicos, estudiantes de medicina y autoridades sanitarias, pero debe ser cuidadosa al compartir información con extraños.

“Gente con malas intenciones ha tratado de vincular a la ERC con el trabajo en la industria azucarera porque esta industria fue la primera en encontrar altas tasas de ERC en los trabajadores que vinieron a las plantaciones en busca de trabajo— dijo Amador—. Y es por estos ataques constantes que las plantaciones y sus empleados son muy cuidadosos a la hora de dar información a cualquier persona o institución”.

Los productores centroamericanos juegan un papel importante en el negocio mundial del azúcar; en 2011, los Estados Unidos importaron más de 330.000 toneladas métricas de azúcar de la región, equivalente a un 23% de las importaciones totales de azúcar sin refinar.

Por debajo de la mesa, el gobierno estadounidense ha promovido enérgicamente la industria azucarera –en las áreas afectadas por la epidemia– no sólo como ingrediente culinario sino como fuente de biocombustible del etanol. Los Estados Unidos patrocinaron conferencias para promover los biocombustibles tanto en Nicaragua como en El Salvador incluso hasta 2008, según cables diplomáticos difundidos por WikiLeaks. Sus embajadores se reunieron en varias ocasiones con los líderes de la industria azucarera de ambos países, angustiados por el posible fracaso en el desarrollo de la producción de etanol, que podría llevar a estas naciones a depender de las importaciones de petróleo de la Venezuela de Hugo Chávez.

En el 2007, el entonces embajador Paul Trivelli notificó al Departamento de Estado de Estados Unidos acerca del primer cargamento de etanol del Ingenio San Antonio y escribió que la compañía había alcanzado “el potencial para desarrollar la industria y los aspectos positivos de los biocombustibles”. Pero manifestó preocupación por la posibilidad de que el presidente izquierdista de Nicaragua, Daniel Ortega, fuera influenciado por Hugo Chávez en su oposición a los biocombustibles. Al año siguiente, Trivelli escribió que el Departamento de Estado había designado a Nicaragua como “un país de alta prioridad” en cuanto a los biocombustibles. La embajada en El Salvador, lindante al norte con Nicaragua, también promovió agresivamente el etanol: los embajadores se reunieron con los líderes de la industria azucarera, hicieron saber al Departamento de Estado sus preocupaciones acerca de los efectos políticos de las importaciones de petróleo de Venezuela, y patrocinaron una conferencia para la promoción de biocombustibles.

Mientras tanto, el Banco Mundial ha proporcionado más de 100 millones de dólares en préstamos para la promoción de la producción de biocombustibles en dos plantaciones severamente afectadas, préstamos que aprobó sin consideración formal de la enfermedad renal. Cuando los trabajadores protestaron, el Banco proporcionó un millón de dólares para patrocinar el estudio en curso de la Universidad de Boston.

Antes de recibir los préstamos, las compañías tenían que demostrarle al Banco que estaban cumpliendo con los estándares sociales y ambientales. Equipos de evaluación publicaron rutilantes informes sobre las prácticas en los Ingenios San Antonio y Monte Rosa en septiembre de 2006 y mayo de 2007. Ninguno menciona la ERC.

En octubre de 2006, la junta de la Corporación Financiera Internacional (IFC) –el prestamista del Banco Mundial para proyectos del sector privado– aprobó un préstamo de 55 millones de dólares para el Ingenio San Antonio. Un préstamo de 50 millones de dólares para el Ingenio Monte Rosa fue aprobado en junio de 2007. Con el dinero, las compañías crecieron, enviando a más trabajadores a los campos de caña.

Edgar Restrepo, director general de inversiones de la IFC, dijo que su equipo sí consideró la ERC cuando evaluó el Ingenio San Antonio, pero que el contenido de sus deliberaciones es privado. Adriana Gómez, vocera de la IFC, dijo que la IFC había “cumplido con sus estrictos estándares sociales y ambientales en el proceso de diligencia debida”.

Punto muerto en Ciudad de México

Aunque los gobiernos de Centroamérica han destinado pocos recursos a la lucha contra la ERC, comienzan a sonar algunas alarmas.

El gobierno de El Salvador hizo una enérgica convocatoria a investigadores internacionales. En una cumbre de Naciones Unidas para ministros de salud que se llevó a cabo en Ciudad de México en febrero de 2011, la ministra de salud de El Salvador, María Isabel Rodríguez, declaró que la enfermedad renal crónica estaba “devastando nuestras poblaciones” a lo largo de Centroamérica. Llamó a sus colegas a que incluyeran la ERC entre las enfermedades crónicas principales en las Américas, paso que podría atraer los fondos de Naciones Unidas para investigación.

Su propuesta chocó con la oposición cerrada del más poderoso participante de la cumbre: los Estados Unidos.

Rodriguez dijo que la delegación norteamericana se rehusó tanto a incluir la enfermedad en la lista de enfermedades crónicas más graves del continente como a aceptar un lenguaje que sugiriera que la epidemia tenía causas claramente relacionadas con la exposición a químicos tóxicos.

Representantes centroamericanos dijeron que se sentían tan indignados que se rehusaban a firmar la declaración final de la conferencia hasta que no se incluyera la ERC. Durante momentos de tensión, la disputa amenazó el consenso alcanzado en la cumbre. El resultado: una sola frase mencionando la enfermedad renal crónica en Centroamérica.

David McQueen, delegado estadounidense del Centro para el Control y la Prevención de las Enfermedades, le dijo al ICIJ que los Estados Unidos se oponían a mencionar la ERC para mantener el énfasis en la diabetes, las enfermedades del corazón y el cáncer.

“Los pronunciamientos que se hacen rara vez son exitosos si no están muy bien dirigidos”, dijo.

McQueen, hoy jubilado, dijo que no estaba al tanto de la dramática expansión de la enfermedad renal crónica hasta que el tema se discutió en la conferencia. “La cuestión del riñón crónico tomó a todo el mundo por sorpresa— dijo—. ¿Por qué están haciendo tanta fuerza por este tema?” MacQueen se enteró en la reunión de que era “un problema importante”, que causaba “una sangría enorme en el presupuesto” de los médicos y hospitales en Centroamérica.

Pero incluso después de conocer el tema, Estados Unidos ha hecho poco al respecto. Kathryn Harben, vocera del CDC, dijo que durante una cena en la noche de la cumbre en Ciudad de México, el CDC se ofreció informalmente a ayudar a los ministerios de salud de Centroamérica. Aún no ha empezado a hacerlo, dijo, porque los ministerios no han presentado una petición formal. El funcionario de salud más importante en la cumbre, el doctor Howard K. Koh, subsecretario de salud en el Departamento de Salud y Servicios Humanos, no quiso ser entrevistado para esta investigación.

Enférmate y perderás tu trabajo

Los Ingenios San Antonio y Monte Rosa, las plantaciones más grandes de Nicaragua, ahora examinan habitualmente a sus trabajadores para medir sus niveles de creatitina en sangre, un químico que indica el funcionamiento de los riñones. Los trabajadores con niveles altos de creatinina son despedidos, una medida necesaria según las compañías para prevenir que los trabajadores enfermos arriesguen aún más su salud en los campos.

El despido deja a los trabajadores sin acceso a los hospitales de las compañías y muchas veces a sus pensiones.

El Ingenio San Antonio dijo que ha reducido las jornadas laborales, que provee más agua y soluciones hidratantes y que contrata trabajadores sociales que acompañan a los contratistas a los campos para asegurar su correcta hidratación. Actualmente, la jornada laboral no tiene más de ocho horas para los trabajos físicamente extenuantes, y la compañía proporciona ocho litros de agua y 2.700 milímetros de solución hidratante por día a cada trabajador, dijo el vocero Granera.

Una mañana de noviembre de 2009, Maudiel Martínez se subió a un bus de la compañía con destino a los campos. Tenía 17 años de edad y comenzaba su cuarto año con el Ingenio San Antonio. La cosecha estaba a punto de comenzar y, siguiendo la rutina, la compañía había llevado a cabo exámenes de sangre para ver si sus trabajadores estaban suficientemente saludables para trabajar en los campos.

Martínez estaba en el bus cuando recibió la noticia: no había pasado el examen de creatinina. Estaba enfermo.

“Lloré de tristeza —dijo Martínez—. Era tan joven. A los 17 años uno es todavía un adolescente”.

El diagnóstico significaba que Martínez tenía prohibido formalmente trabajar para la compañía. Con una familia en graves aprietos económicos y sin alternativas de trabajo, Martínez tomó un nombre y un número de seguridad social falsos y regresó a trabajar a los mismos campos para un contratista independiente al que, como dijo Martínez, poco le importaba que éste tomara el nombre y el número de seguridad social de una mujer.

Al menos algunos trabajadores bajo contrato siguen cumpliendo turnos más largos y más riesgosos. Un periodista del ICIJ notó en junio de 2011 que los buses que recogían trabajadores bajo contrato para el Ingenio San Antonio salían a las 5.25 de la mañana y regresaban a las 5.31 de la tarde. Los trabajadores decían que pasaban unas diez de esas horas en los campos.

Colapso en los campos

El 10 de junio de 2011 a Martínez se le ordenó cortar cuatro hileras de caña. Su tarea consistía en pelar las hojas, cortar las cañas en pedazos y reunirlas en atados. Alrededor de cuarenta piezas forman un atado. Por este trabajo recibió una córdoba por atado –menos de cinco centavos de dólar.

A las 8:30 de la mañana había cortado dos hileras. Empezó a sentirse mal, pero continuó cortando bajo el calor abrasador. “El sol estaba demasiado fuerte y yo sudaba a través de mi camiseta como si me hubieran echado agua encima”, recordó Martínez.

Cuando había terminado sus hileras, cerca de las once, Martínez tenía fiebre y sentía náuseas. Descansó 15 minutos pero aún tenía que armar los atados. Otro trabajador vino en su ayuda.

Martínez dijo que terminaron a la 1 de la tarde, y el bus vino media hora después a recoger a los trabajadores para llevarlos a la casa. Cuando llegó, Martínez se sentía desesperadamente enfermo. “Me subí al bus y ya no pude caminar”, dijo.

Como Martínez era un trabajador por contrato, no podía ir al hospital de la compañía. Tomó el bus hacia su casa y empezó a vomitar. El bus no paró.

“Los muchachos me dejaron sacar la cabeza por la ventana del bus”, dijo.

La calle donde el bus lo dejó está separada de su casa por un riacho. Su madre y su hermano lo cargaron desde allí hasta la cama.

Pronto después de su colapso, Martínez supo que sus niveles de creatinina estaban altos. Llevaba días sin apetito, tomando sólo bebidas frías para aplacar la sensación de fiebre.

“Si la muerte viene en camino, tenemos que resignarnos a esperarla— dijo Martínez—. Resignarse quiere decir esperar lo que la enfermedad te va a traer. Porque tú me miras ahora y parezco normal, pero por dentro estoy como en llamas”.