I’ve written twice before on this blog about an emerging disease in Central America called Chronic Kidney Disease. In my original post I described how in some communities in the region between a quarter and seventy percent of men may suffer from the disorder, which is a truly staggering number. In a subsequent post, I argued that something mysterious was happening in Central America, because the disease appears to be something new. While some people argue that the illness takes place because of pesticide exposure or dehydration, this argument seems problematic to me. If this is true, why do we not see a similar illness in the Caribbean or the Atlantic coast of Brazil? That is why in this post I suggested changing the name of the disorder to EKD, so as to reflect the disease’s novelty. The fact that the illness focuses on the Pacific Coast of Central America, mainly affects men, but also seems to impact workers outside the sugar cane industry, all seems significant to me.
Although I haven’t posted on this topic recently, I’ve continued to follow news from the region. Recently, the Batahola Volunteers in Nicaragua had a blog post that talked about a confrontation with police, which led to the death of a man named Juan de Dios Cortes. He had been suffering from CKD/EKD, and had been taking part in a labor protest outside of the Nicaragua Sugar Company, to demand that the company help to care for its sick employees. He was killed by a police bullet, and at least one other protester was injured. Afterwards, two of the Batahola volunteers visited with the sugar-cane workers to learn about their grievances and their experience with the illness. Erika Coe wrote a beautifully written piece based on these conversations, which conveyed the social impact of the disease in Chichigalpa, Nicaragua, one of the worst hit communities. So far, 7,982 people have died from the illness in the region, and the disease shows no signs of waning. Although journalists and others have sought to bring international attention to CKD (EKD), what is still needed is a large-scale, well-funded multi-national epidemiological study, far greater in size than anything attempted to date.
Shawn Smallman, Portland State University
Shawna,
Thoughtful post. Would love to talk more with you.
Just going to address a few points here:
1. Brazil: The disease may have been affecting workers in Brazil before major changes in the last 2 decades to how work was carried out. They now have basic access to water.rest.shade and La Isla Foundation (LIF) is now working with the US Dept of Labor to bring a version of OSHA’s water.rest.shade program to affected countries through ILAB https://www.osha.gov/SLTC/heatillness/index.html?utm_source=Twitter It’s still early but we really think this is a great way to make worker protection a policy in countries like El Slavador and Costa Rica that are more open to such progressive policies.
2. Caribbean: In Cuba the work force has not had these exposures to either pesticides or massive dehydration due to brutal work practices in over 5 decades. As far as it occurring in the DR or other Caribbean areas A. I don’t think anyone has been asking the Hatian migrants if they’re sick in the DR and workers in most of the other countries do not suffer from the same lack of work protections as those in C.A.. A prevalence study needs done, and soon in those areas though, the statements that it does not exist are not true, they’ve not been evaluated. B. The other cane producing islands do not have near the productivity that Central American plantations do and have generally much better conditions. Central America is the wild west in terms of work practices. Workers cut many more tons of cane today, have fewer labor protections and are generally more at risk due to their living standards.
3. Not New: The disease is not new. It is at least 30 years old according to mortality data. Probably older when you look at the history of cane workers. Looking at documents naming the average age of death of slaves and the average age of death of workers in the early-mid 20th century you’ll find that they die of ‘exhaustion’ in their 40s-50s. The average age of death for workers in Chichigalpa is 46.
The point here is that no one bothered to ask these people if they were sick or what was happening to them until about 10 years ago. Leaked company data from Chichigalpas sugar mill show they found that heat stress and pesticide exposure were the main causes, and then hid it for over a decade until it was leaked. We’ve been following the science and have come to some similar conclusions independently.
Brazil is an interesting case and has had mechanised and improved production standards for over a decade, while Cuba has long had a rigorous protocol for cane workers. Making a direct correlation here is not accurate and is not what science or investigation entail. It frankly serves to support industry claims that mutate as it suits them. Be careful in your queries and you’ve got to dive deeper into the data.
You’ve got to look at all the factors, living conditions and work practices chief among them of course. They vary greatly. For instance, in Veracruz the average cane cut by one worker is 1-3 tons a day, very low. In Nicaragua and Guat, you’re talking 8-12. That’s a lot more fluid loss and a lot more toxin exposure and a lot more heat stress.
4. Dehydration, poisons, and sugar: Diets have changed radically in the last 30 years, the work practices have gotten worst and not better, the globe hotter and pesticides will accumulate over time as I’m sure you know. We started studying dehydration as we were looking at the issue that could be first addressed comparatively cheaply and would also protect against other risks. These men are losing 2.4 kilograms a day in water. We have proven, as you can see in our publication in Nature’s Kidney Int’l: http://www.nature.com/ki/journal/vaop/ncurrent/full/ki2013492a.html#aff3
that dehydration, combined with sugar metabolism at that point of heat stress is enough to bring on CKD and fairly rapidly.
A follow up field and lab study are inbound and further strengthen that case. Now, you combine that with the fact that workers are given gatorade like fluids by employers and bring their own sugary fluids to hydrate with at work and you’ve got one part of the problem demonstrated. Their fluid loss is that extreme and therefore the pathway causing the damage that much worse. Now, if you lose that much fluid your osmolarity goes up which makes you far more susceptible to whatever toxins exposure you’re faced with. Depending on the region/job (construction, mining, cane, rice (sri lanka and India seem to have this too)) it could be silica, arsenic, cadmium, paraquat, 24d, NSAIDs. All of them will cause more damage now in this vulnerable state.
Finally, these people live in extreme poverty, with terrible access to medicine, to a good diet and to rest, the muscle breakdown alone of working 6-7 days a week like this will cause damage to the kidney.
5. Focusing on occupation and moving forward: So, this really does permit the use of that tired perfect storm analogy. It is the case here, these men really have so many risks facing them and their kidney health and it remains to be seen if this is or is not actually in the Caribbean or some of the more backwards parts of Brazil. Prevalence studies of the work force have not been carried out. Public health data in those areas should not be relied on given the almost invisible nature of much of the workforce in the DR specifically. While much needs to be studied, and much is left to be understood we do know we need to address work practices ASAP and that should give these men a fighting chance. That said, there is base line damage in women and young people, so our next focus is going to be a rigorous environmental analysis. While there is one outlier community in the highlands of El Salvador where men and women are equally dying, it seems it does not fit the profile and a large Toxaphene dump has been found. This tells us that there may be variations in some areas and is a reminder that there have been isolated epidemics of kidney disease all over the world. However, the profile of heavy labor, hot climate, poor access to care, sugar consumption and pesticide use finds heavy agricultural works to be most at risk, and no work is more brutal than cane work in terms of heat stress, exposures and poor work protections.
LIF just got 4 million dollars with our partner org, Solidaridad to tackle more studies and bring direct aid to severely affected communities. I’d LOVE to work with Portland State University, especially the excellent GIS program in helping us understand more and protect more life. contact me at jason@laislafoundation.org
There is still mystery around all the dynamics but the science is showing us it’s already possible to protect these people and heat stress and exposures are indeed part of the problem. We’d love to work with PSU. Contact us.
Thanks Jason for this detailed and thoughtful response. Yes, I will be in touch because I’d like to hear a little bit more about ILF’s specific needs regarding GIS. I can’t promise anything, but I’m willing to go talk to the people in the program here at PSU to see if there are faculty/graduate students who might be willing to help. But it will be good to have some more sense of the context and work first. Shawn