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Deadly kidney illness in Central America baffles health researchers

By Heather Murphy
New York Times
  • http://media.charlotteobserver.com/smedia/2014/05/10/00/05/eiZN8.Em.138.jpeg|316
    MERIDITH KOHUT - NEW YORK TIMES
    Workers are given high-sugar content water packs in February to prevent dehydration while harvesting sugar cane at the San Antonio sugar mill in Chichigalpa, Nicaragua. Nicaragua’s vital sugar cane heartland has been one of hardest hit places in the world by a mysterious kidney disease, with multiple generations of cane cutters dying in the same family and seemingly healthy young men quickly wasting away.
  • http://media.charlotteobserver.com/smedia/2014/05/10/00/05/eD69D.Em.138.jpeg|210
    MERIDITH KOHUT - NEW YORK TIMES
    Six-year old Harissiebrehth Joel Martinez admires a portrait of his father, Carlos Jose Martinez Rivas, who died from a kidney disease that has afflicted many workers in the area, in Chichigalpa. Nicaragua’s sugar cane heartland has been devastated by an illness that has killed tens of thousands of people and is so poorly understood that it has no agreed upon name.

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CHICHIGALPA, Nicaragua During the harvest season, when exhausted workers spend seven days a week cutting sugar cane, the signs of illness were hard to spot at first.

It was in the offseason, out on the baseball field, that some residents noticed a change. Base-stealers were lethargic. Pitchers were losing their aim. In the evening, outfielders were burning up as if standing under the scorching sun of the day.

“That’s Mosquito, now dead,” said Arnulfo Téllez Aguilera, 49, pointing to a photograph of his smiling teammates before their muscles withered, like his. “That’s my brother, Danilo, dead too.”

Across Central America, a painful disease that affects the kidneys has killed at least 20,000 people over the past decade and has become the leading cause of deaths in hospitals among men in El Salvador. But the illness, often called Chronic Kidney Disease of unknown causes, or CKDu, is so poorly understood that it still does not have a universally agreed upon name.

Theories vary drastically, citing a combination of possible factors, including heat stress, chronic dehydration, pesticides, painkillers, sugar consumption and even volcanic ash. But there is a rare point of consensus, many researchers say: Nicaragua’s sugar cane heartland – in particular Chichigalpa, the town that is home to the country’s largest sugar mill – has been one of the hardest hit places in the world. Cane-cutting fathers and sons in the same family have died, and seemingly healthy young men are quickly wasting away.

The Nicaraguan government, the country’s sugar mills, even the World Bank, which has poured tens of millions of dollars into the sugar industry here, all say that until the mystery of the disease is solved, there is little they can do to prevent it. Now, after years of inconclusive research, the Centers for Disease Control and Prevention is stepping in to help with some of the most ambitious studies of the illness yet.

But the sick former sugar cane workers here have little faith that more studies will bring improvements anytime soon. The fact that the research will be funded entirely by the sugar industry is only fueling the distrust.

“I don’t think anybody has clean hands,” said Kristen Genovese, a lawyer who helped sick former workers file a complaint against the World Bank’s lending arm in 2008 for loaning $55 million to the sugar mill, called San Antonio, without looking into the disease or the possibility that it might be connected to the industry.

“The government of Nicaragua has done nothing to help these people,” said Genovese, who was with the Center for International Law in Washington when she filed the complaint. And the World Bank, she argued, “should have spotted this problem, and didn’t do anything about it, and continued to invest in sugar in the region.”

Lawmakers in El Salvador and Sri Lanka, where similar kidney problems have emerged, have moved to ban certain pesticides. But few of the researchers who are focusing on Nicaragua – the country with the highest death rate from the disease, according to the Pan American Health Organization – are willing to say the answer is that simple.

Pesticides alone, they say, do not explain why the disease has been detected in some Nicaraguan miners at similar rates, why women who grew up on the sugar mill’s grounds have generally been unscathed, or why workers here are affected at much higher rates than people exposed to the same chemicals elsewhere. Perhaps extreme heat, dehydration, the intensity of the labor or other factors play a role, the researchers say.

“The problem is this is a silent killer,” said Aurora Aragón, a Nicaraguan researcher.

Unsuccessful lawsuits

Residents say they began noticing the sickness shortly after the Nicaraguan government, which had nationalized the sugar industry, returned the mills to private owners in 1992. As the operations at San Antonio rapidly expanded, driven partly by U.S. and European appetites for sugar and a move into ethanol production, families say the cane cutters – many of whom had been born in a hospital on the mill grounds and went to a school there – grew sick in larger numbers.

The mill says it pays the government every year so that workers can receive pensions and health insurance. Without a scientifically decisive link to the disease, industry officials question why they should be responsible for more.

Throughout the early 2000s, lawsuits seeking compensation from the mill mostly went nowhere. Then in 2008, a workers’ group known as the Association of Chichigalpinos for Life filed the complaint against the World Bank’s lending arm, known as the International Finance Corp., which had lent the mill $55 million.

When deciding whether to invest in the industry, no one had brought up or looked into the disease, a spokesman for the finance corporation said.

“CKD is not a common disease in the sugar sector worldwide, so IFC did not look into this issue at appraisal,” said the spokesman, Aaron Rosenberg, based in Washington. The institution has lent more than $100 million dollars to Nicaraguan sugar mills over the past decade.

Broad implications

After the complaint, the mill agreed to provide food and other assistance to widows and sick workers. It also agreed to open its door to a team of outside researchers.

Yet “nature can be very reluctant to give up its secrets,” said Daniel Brooks, a researcher from Boston University, which was selected to investigate the disease by a committee that included sick workers and mill executives.

Five years later, Brooks has as many questions about the disease as answers. His report published in 2012 neither entirely ruled out nor formally endorsed any theory.

Now, Brooks and his team from Boston University will be leading the charge in three CDC Foundation studies, which he believes could have implications far beyond Nicaragua.

“We don’t know if this is the tip of the iceberg yet,” he said. “If this is heat stress and the climate is changing in the direction of getting hotter over time, are we seeing something that will happen much more in the future and maybe extend its geographic range?”

“Similarly, if it’s agrochemicals, the agrochemicals they use are very widespread across the whole world,” he added.

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