Mystery disease kills thousands in Central America

Associated Press

Associated Press

Saturday, February 11, 2012

CHICHIGALPA, Nicaragua (AP)  
Ignacio Flores started working when he was 16, 
laboring long hours on construction sites and in 
the fields of his country's biggest sugar plantation.

Three years ago his kidneys started to fail and 
flooded his body with toxins. He became too weak 
to work, wracked by cramps, headaches and vomiting.

On Jan. 19 he died on the porch of his house. He 
was 51. His withered body was dressed by his 
weeping wife, embraced a final time, then carried 
in the bed of a pickup truck to a grave on the 
edge of Chichigalpa, a town in Nicaragua's 
sugar-growing heartland, where studies have found 
more than one in four men showing symptoms of chronic kidney disease.

A mysterious epidemic is devastating the Pacific 
coast of Central America, killing more than 
24,000 people in El Salvador and Nicaragua since 
2000 and striking thousands of others with 
chronic kidney disease at rates unseen virtually 
anywhere else. Scientists say they have received 
reports of the phenomenon as far north as 
southern Mexico and as far south as Panama.

Last year it reached the point where El 
Salvador's health minister, Dr. 
Isabel Rodriguez, appealed for international 
help, saying the epidemic was undermining health systems.

Wilfredo Ordonez, who has harvested corn, sesame 
and rice for more than 30 years in the Bajo Lempa 
region of El Salvador, was hit by the chronic 
disease when he was 38. Ten years later, he 
depends on dialysis treatments he administers to himself four times a day.

"This is a disease that comes with no warning, 
and when they find it, it's too late," Ordonez 
said as he lay on a hammock on his porch.

Many of the victims were manual laborers or 
worked in sugar cane fields that cover much of 
the coastal lowlands. Patients, local doctors and 
activists say they believe the culprit lurks 
among the agricultural chemicals workers have 
used for years with virtually none of the 
protections required in more developed countries. 
But a growing body of evidence supports a more 
complicated and counterintuitive hypothesis.

The roots of the epidemic, scientists say, appear 
to lie in the grueling nature of the work 
performed by its victims, including construction 
workers, miners and others who labor hour after 
hour without enough water in blazing 
temperatures, pushing their bodies through 
repeated bouts of extreme dehydration and heat 
stress for years on end. Many start as young as 
10. The punishing routine appears to be a key 
part of some previously unknown trigger of 
chronic kidney disease, which is normally caused 
by diabetes and high-blood pressure, maladies 
absent in most of the patients in Central America.

"The thing that evidence most strongly points to 
is this idea of manual labor and not enough 
hydration," said 
Brooks, a professor of epidemiology at 
of Public Health, who has worked on a series of 
studies of the kidney disease epidemic.

Because hard work and intense heat alone are 
hardly a phenomenon unique to Central America, 
some researchers will not rule out manmade 
factors. But no strong evidence has turned up.

"I think that everything points away from 
pesticides," said Dr. Catharina Wesseling, an 
occupational and environmental epidemiologist who 
also is regional director of the Program on Work, 
Health and Environment in Central America. "It is 
too multinational; it is too spread out.

"I would place my bet on repeated dehydration, 
acute attacks everyday. That is my bet, my guess, but nothing is proved."

J. Johnson, a kidney specialist at the 
of Colorado, Denver, is working with other 
researchers investigating the cause of the 
disease. They too suspect chronic dehydration.

"This is a new concept, but there's some evidence 
supporting it," Johnson said. "There are other 
ways to damage the kidney. Heavy metals, 
chemicals, toxins have all been considered, but 
to date there have been no leading candidates to 
explain what's going on in Nicaragua ...

"As these possibilities get exhausted, recurrent 
dehydration is moving up on the list."

In Nicaragua, the number of annual deaths from 
chronic kidney disease more than doubled in a 
decade, from 466 in 2000 to 1,047 in 2010, 
according to the 
American Health Organization, a regional arm of 
the World Health Organization. In El Salvador, 
the agency reported a similar jump, from 1,282 in 2000 to 2,181 in 2010.

Farther down the coast, in the cane-growing 
lowlands of northern Costa Rica, there also have 
been sharp increases in kidney disease, Wesseling 
said, and the Pan American body's statistics show 
deaths are on the rise in Panama, although at less dramatic rates.

While some of the rising numbers may be due to 
better record-keeping, scientists have no doubt 
they are facing something deadly and previously unknown to medicine.

In nations with more developed health systems, 
the disease that impairs the kidney's ability to 
cleanse the blood is diagnosed relatively early 
and treated with dialysis in medical clinics. In 
Central America, many of the victims treat 
themselves at home with a cheaper but less 
efficient form of dialysis, or go without any dialysis at all.

At a hospital in the Nicaraguan town of 
Chinandega, Segundo Zapata Palacios sat 
motionless in his room, bent over with his head on the bed.

"He no longer wants to talk," said his wife, 

His levels of creatinine, a chemical marker of 
kidney failure, were 25 times the normal amount.

His family told him he was being hospitalized to 
receive dialysis. In reality, the hope was to 
ease his pain before his inevitable death, said 
Rios, a leader of Nicaragua's Association of 
Chronic Kidney Disease Patients, a support and advocacy group.

"There's already nothing to do," she said. "He 
was hospitalized on Jan. 23 just waiting to die."

Zapata Palacios passed away on Jan. 26. He was 49.

Working with scientists from Costa Rica, El 
Salvador and Nicaragua, Wesseling tested groups 
on the coast and compared them with groups who 
had similar work habits and exposure to pesticide 
but lived and worked more than 500 meters (1,500 feet) above sea level.

Some 30 percent of coastal dwellers had elevated 
levels of creatinine, strongly suggesting 
environment rather than agrochemicals was to 
blame, Brooks, the epidemiologist, said. The 
study is expected to be published in a peer-reviewed journal in coming weeks.

Brooks and Johnson, the kidney specialist, said 
they have seen echoes of the Central American 
phenomenon in reports from hot farming areas in 
Sri Lanka, Egypt and the Indian east coast.

"We don't really know how widespread this is," 
Brooks said. "This may be an under-recognized epidemic."

Jason Glaser, co-founder of a group working to 
help victims of the epidemic in Nicaragua, said 
he and colleagues also have begun receiving 
reports of mysterious kidney disease among sugar cane workers in Australia.

Despite the growing consensus among international 
Brizuela, a doctor who works with an 
Salvadoran project to treat workers and research 
the epidemic, discounts the dehydration theory 
and insists "the common factor is exposure to herbicides and poisons."

Nicaragua's highest rates of chronic kidney 
disease show up around the Ingenio San Antonio, a 
plant owned by the 
Group conglomerate, whose sugar mill processes 
nearly half the nation's sugar. Flores and Zapata 
Palacios both worked at the plantation.

According to one of Brooks' studies, about eight 
years ago the factory started providing 
electrolyte solution and protein cookies to 
workers who previously brought their own water to 
work. But the study also found that some workers 
were cutting sugar cane for as long as 9 1/2 
hours a day with virtually no break and little 
shade in average temperatures of 30 C (87 F).

In 2006, the plantation, owned by one of the 
country's richest families, received $36.5 
million in loans from the 
Finance Corp., the private-sector arm of the 
World Bank Group, to buy more land, expand its 
processing plant and produce more sugar for consumers and ethanol production.

In a statement, the IFC said it had examined the 
social and environmental impacts of its loans as 
part of a due diligence process and did not 
identify kidney disease as something related to 
the sugar plantation's operations.

Nonetheless, the statement said, "we are 
concerned about this disease that affects not 
only Nicaragua but other countries in the region, 
and will follow closely any new findings."

Ariel Granera, a spokesman for the Pellas' 
business conglomerate, said that starting as 
early as 1993 the company had begun taking a wide 
variety of precautions to avoid heat stress in 
its workers, from starting their shifts very 
early in the morning to providing them with many 
gallons of drinking water per day.

Associated Press reporters saw workers bringing 
water bottles from their homes, which they 
refilled during the day from large cylinders of 
water in the buses that bring them to the fields.

Glaser, the co-founder of the activist group in 
Nicaragua, La Isla Foundation, said that 
nonetheless many worker protections in the region 
are badly enforced by the companies and 
government regulators, particularly measures to 
stop workers with failing kidneys from working in 
the cane fields owned by the Pellas Group and other companies.

Many workers disqualified by tests showing high 
levels of creatinine go back to work in the 
fields for subcontractors with less stringent 
standards, he said. Some use false IDs, or give 
their IDs to their healthy sons, who then pass 
the tests and go work in the cane fields, damaging their kidneys.

"This is the only job in town," Glaser said. 
"It's all they're trained to do. It's all they know."

The Ingenio San Antonio mill processes cane from 
more than 24,000 hectares (60,000 acres) of 
fields, about half directly owned by the mill and 
most of the rest by independent farmers.

The trade group for Nicaragua's sugar companies 
said the Boston University study had confirmed 
that "the agricultural sugar industry in 
Nicaragua has no responsibility whatsoever for 
chronic renal insufficiency in Nicaragua" because 
the research found that "in the current body of 
scientific knowledge there is no way to establish 
a direct link between sugar cane cultivation and renal insufficiency."

Brooks, the epidemiologist at Boston University, 
told the AP that the study simply said there was 
no definitive scientific proof of the cause, but 
that all possible connections remained open to future research.

In comparison with Nicaragua, where thousands of 
kidney disease sufferers work for large sugar 
estates, in El Salvador many of them are 
independent small farmers. They blame 
agricultural chemicals and few appear to have 
significantly changed their work habits in 
response to the latest research, which has not 
received significant publicity in El Salvador.

In Nicaragua, the dangers are better known, but 
still, workers need jobs. Zapata Palacios left 
eight children. Three of them work in the cane fields.

Two already show signs of disease.

Associated Press writer Filadelfo Aleman reported 
this story in Chichigalpa, Nicaragua, and Michael 
Weissenstein reported from Mexico City. AP 
writers Marcos Aleman in Bajo Lempa, El Salvador, 
and Romina Ruiz-Goiriena in Guatemala City contributed to this report.

Mitchel's comment:
My bet is that the diseases are caused by 
microorganisms in the fertilizers being used. I 
wonder if the same diseases are occurring on 
organic and fertilizer-free farms. It's simply 
amazing that some "scientists" are blaming this 
on workers' lifestyles (not drinking enough 
water) as though not until recently did sugar 
cane workers labor under severe conditions 
stressing the body. It's probably not that 
they're not drinking sufficient water, but it's 
worth looking at what's in the water that they are drinking.

- Mitchel Cohen

Ring the bells that still can ring,  Forget your perfect offering.
There is a crack, a crack in everything, That's how the light gets in.
~ Leonard Cohen