The Price of Sugar: Investigating the epidemic of Chronic Kidney Failure in rural Nicaragua

By Eleanor Marshall

You can’t find a good restaurant in Chichigalpa, Nicaragua, but you can take your pick of coffins.

New casket shops have cropped up, and the cemetery has expanded. The business of burials is one of the only industries booming in this rural community where the annual death toll from Chronic Kidney Disease (CKD) has doubled in the last two years, from 445 in 2010 to 1,092 in 2012. A study from La Isla Foundation, a non-profit that works in Chichigalpa, reports that 75 percent of deaths in men ages 35-55 and 46 percent of all male deaths are directly attributable to CKD.

The community’s full name is not simply “La Isla” but “La Isla de las Viudas,” or “Island of the Widows,” and it is encircled by an expanding sea of sugar cane. In those waving rows of cane lies the epicenter of the CKD epidemic plaguing the rural populations of Nicaragua.

Official records show that 20,000 men have died prematurely from CKD, thought to be caused by factors including dehydration and heat exposure. Although Ilana Weiss, director of policy and public health for La Isla Foundation, predicted the true toll is much higher. She explained that many cases go unreported as workers lack access to medical care, or can’t afford it. In agricultural areas of Nicaragua and Costa Rica, kidney failure occurs at five times the national rate. In El Salvador, it was the second highest cause of death in 2009. Not contained to Central America, CKD has been observed in equatorial regions of Sri Lanka, India, and the Philippines among various agriculture-based communities.

Weiss remembered meeting one 20-year-old worker last year who had just finished his first season in the sugar cane, and was about to start his second. She was with him for his first blood test mandated by the San Antonio Sugar Mill, the largest employer in La Isla. Exams showing high levels of creatinine, a chemical metabolized by working kidneys, result in immediate dismissal of workers to avoid company liability for the illness. As the health of workers deteriorates, they are almost always denied pensions or compensation by the company and social security benefits by the government.

“We’re on the way to the testing center and I ask him if he’s nervous,” she remembered. “He looks at me with this huge smile on his face and is like, ‘No. We were born to die in the cane fields.’”

The spread of sugar

Though the unforgiving labor of sugar cane cultivation around the equator is centuries old, the kidney failure epidemic has only become rampant in the last few decades, and serious work on producing a body of reliable research began in the late 2000s. According to Jean Silk, program manager of the Yale Council for Latin and Iberian Studies, CKD appears to have spread with major expansions of large-scale sugar cane operations in the last ten years. The rising global demand for sugar, expected to increase 25 percent by 2020 to feed expanding appetites for processed foods and the burgeoning ethanol industry, has brought in international loans for major corporations to expand cane production.

A Nicaraguan worker harvests sugar cane. Chronic Kidney Disease is a major cause of death among Nicaraguan men (Courtesy of Jean Silk).
A Nicaraguan worker harvests sugar cane. Chronic Kidney Disease is a major cause of death among Nicaraguan men (Courtesy of Jean Silk).

On October 25, 2006, the International Finance Corporation (IFC), a World Bank group, approved a $55 million loan to Nicaragua Sugar Estates Limited, the umbrella corporation that owns San Antonio Sugar Mills and oversees production of 24,000 hectares of cane cultivation in the region encompassing La Isla. The loan was intended to increase production across an additional 2,482 hectares of land, increase mechanization, and fund the construction and operation of a new ethanol plant.

According to Olivia Kaplan FES ’08, San Antonio had expanded to the rural village of Goyena, New Haven’s sister city, by 2003, a few years before she arrived. When she began work there in 2005, farmers had already initiated complaints through the local courts that pesticide run-off from neighboring cane fields was contaminating the water and that aerial sprays were causing crop failure and sickness.

She returned in 2006 to conduct interviews in Chichigalpa, and found households emptied of their patriarchs. According to Kaplan, the community of 10,000 lost 2,500 people to CKD within a five-year period as diagnosed by San Antonio’s own exams. In fact, the corporation had planted palm trees to line the promenade at its entrance, and would frequently carry lines of coffins to the gates in what resembled traditional funeral processions.

“I came back and walked around shell-shocked because of what I had seen in Nicaragua. It was lots of deteriorating bodies,” she said. “Unconsciously, out of my mouth, I promised the sugar cane workers in Chichigalpa that I would try to do something that would get them justice.”

Behind the collapse

While the effects of CKD are ubiquitous in the coffin stores and fatherless households of Chichigalpa, pinning down the cause of the disease still proves the largest barrier to solving it.

Currently, the strongest hypothesis is that such high incidence of the disease comes from repeated exposure to intense heat – often hovering near 100°F and increasing with the effects of climate change – combined with dehydration resulting from strenuous labor without adequate breaks or access to water. Weiss explained that sugar cane workers lose over five pounds of water per day – the average amount runners lose during a marathon, except over and over again without recovery time. Rehydration would require drinking an estimated 19 liters of water per day – more than the body can absorb, she explained.

The effects of dehydration make it difficult for the kidney to process environmental toxins or digest large quantities of sugar. Unfortunately, sugar cane laborers are exposed to both. Daily, workers apply pesticides or are exposed to aerial sprays without protection. And Maddy Sharp ’13 explains that, ironically, the harms of sugar follow workers out of the field, as sugary beverages are pervasive in Nicaraguan culture while fresh fruits and vegetables, or even potable water, are often unavailable or unaffordable.

After writing her senior thesis on CKD, Sharp arrived in Leon, Nicaragua, on September 24, 2013, to conduct a yearlong project focused on preventative measures – targeting young children and their parents and teachers to provide access to healthy food and education on better nutrition and hydration – habits that can slow the progression of CKD in its early stages.

“When I heard about this illness, I assumed that it was predominantly men in the sugar cane industry, but we’re finding more and more that it has also spread to women and children. Yesterday, I was talking to the town leader of Goyena and she was saying that her son has CKD. There are children in Goyena that have CKD,” Sharp said. “It’s becoming like the common cold, it’s not shocking anymore.”

Born to die in the cane fields

Juan Salgado started work in the sugar cane fields in 1975, before CKD became a household presence. He hails from Candelaria, a village neighboring La Isla where San Antonio began involuntarily resettling workers living on its property in 1998. He regularly worked from 6 a.m. to 6, or even 8 p.m.

“You can’t rest. The only time you rest is if you can’t work and have to go to the hospital,” he said, explaining that workers do not even take breaks to hydrate. “Drinking water wastes time.”

After cutting sugar cane for 36 years, Salgado fell ill with CKD in 2001. Suffering from vomiting, fevers, and intense fatigue, he was forced to retire. The father of five, Salgado’s sons now support the family, but he said many of his neighbors have no one left who is healthy enough to work.

Sugar cane burning in Nicaraguan fields (Courtesy of Jean Silk).
Sugar cane burning in Nicaraguan fields (Courtesy of Jean Silk).

It is consensus among researchers, according to Silk, that workers start to fall ill after just two or three seasons swinging a machete in the sugar cane. Progressing rapidly through the five stages of kidney failure, they die shortly thereafter.

Although Salgado remembered watching fellow workers lose kidney function as early as the late 1980s, and sensed growing alarm in Candelaria over the disease by the early 2000s, just ten years ago, CKD was unheard of outside the isolated communities it impacts.

Because the vast majority of the population across the Nicaraguan countryside is made up of an unskilled, unemployed workforce, Weiss explained that companies like San Antonio have historically treated laborers as easily replaceable. She believes that NSEL is just now being confronted with international pressure to address its labor standards, but is worried about the liability that comes with taking responsibility for occupational illness in its workers.

Y-Vonne Hutchinson, director of law and human rights at La Isla, said that while CKD has become an eventuality for sugar cane workers, they continue to go to work in the fields because companies like San Antonio offer one of the only forms of steady employment to isolated rural communities. Desperate to provide for their families, Hutchinson explains that men suffering from CKD often use false identification to continue working in the fields as sub-contracted labor.

Sugar cane workers are paid on commission, about $0.90 USD for every ton of cane they cut. According to a report by La Isla, workers make, on average, $7 USD per day, working as hard as they can through the six month season that lasts from November through May, hoping this income will make ends meet until the next year. While prices have soared in Nicaragua over the past decades, wages have stagnated.

An occupational hazard

Searching for scientific evidence of the harms of cane cultivation, Kaplan began a study into Goyena’s water quality conducted through the Yale School of Forestry in 2007. When it came back without traceable levels, she began searching for other mechanisms to stop the disease’s spread. She was doing research late one night when she happened upon the IFC’s Office of the Compliance Advisor Ombudsman, through which the populations impacted by the IFC’s projects – like the $55 million loan to sugar companies including San Antonio – can file grievances, outlining the impacts on their communities.

“I literally fell of my chair and was like ‘those sons of bitches.’ Then I knew that something major was going to happen because [the community impacts] listed under the loan were untrue,” she said, leaving ample grounds for grievances.

Kaplan returned to Nicaragua several times over the next few years, meeting with affected populations and partnering with ASOCHIVIDA, an association of former cane workers, to help them build a case. They successfully submitted a formal grievance to the IFC on March 31, 2008.

The report asked Nicaragua Sugar Estates Limited (NSEL), most basically, to comply with IFC and domestic labor laws through practices such as providing breaks

and job rotation for its workers and ensuring potable water in all surrounding communities. San Antonio was required to provide food aid to sick workers for two and a half years after their dismissal and fund construction of a kidney dialysis clinic in Chichigalpa. But the biggest benefits, Kaplan argued, were in the dialogue itself.

“In 2006, the attitude was, ‘We’re dying and the world doesn’t care. Can you please go and tell our story?’” she said. In 2008, IFC investigations brought San Antonio to the negotiating table for the first time, and resulted in a mandated two-year study into the cause of CKD. Published in December 2011, the investigation led by Dan Brooks of Boston University was inconclusive, but corroborates the current theories of dehydration and has paved the way for further international attention.

The cost of living

CKD is treatable through kidney transplants or dialysis, a process that simulates kidney function by removing waste from the bloodstream. However, treatment options are costly and there is no cure. Peritonial dialysis, the cheapest choice, can be administered in a patient’s home, but requires a sterile environment and ample medical supplies, and is extremely painful. Further, one round of peritoneal dialysis costs $100, and treatment requires three rounds per week. It would take almost two months of wages for a sugar cane worker to afford a full week of treatment.

Salgado, like many who suffer from CKD, has refused treatment even when it was available. He explained that in his community, it is the prevailing belief that attempting dialysis will only cause a patient to die more quickly. And, according to Weiss, they are often right. As recently as a few months ago, the majority of dialysis patients were dying from infection during treatment.

Even encouraging people to drink more water can be complicated, explains Connor Bell MPH ’15, who worked on a team with Dan Brooks to conduct research on dehydration in Nicaragua last summer. Many rural communities lack potable water, and believe their wells to be contaminated.

In fact, according to Bell, there is an inexplicably high prevalence of kidney disease among the general population – not just those exposed to the sugar cane – and that there isn’t enough evidence to call CKD an occupational illness.

Citing this lack of a direct connection between the sugar industry and CKD, in 2013, the IFC approved a $15 million loan to Nicaraguan sugar cane producer Montelimar Mill to more than double production. This was the first international loan to a sugar cane company since the IFC’s investigation into CKD began.

But even without a causal link, Bell said, corporations like San Antonio and Montelimar are notorious for mistreating their workers, even suppressing dissent

and political demonstrations with violence, and denying researchers and advocates access to information on working conditions. For Hutchinson, the plight of sugar cane workers is rare in the realm of human rights crises in one important way: it’s solvable.

“We’re not talking about changing an entire government. We’re not talking about eliminating some deeply seated ethnic conflict. We’re not talking about changing cultural perceptions of women. We’re talking about getting a few companies to obey laws on the books and getting a state to protect its workforce. It’s actually quite simple,” she said. “There is a finish line.”

But the prevalence throughout the general population is perhaps more deeply rooted – in lack of access to clean water and nutritious food, and the cultural prevalence of sugary beverages and alcohol. Even getting occupational grievances recognized by companies like San Antonio has required years of constant pressure for slow and small improvement.

“If there was a clear path, I would have gone down it,” Kaplan said.

Eleanor Marshall ’16 is in Saybrook College. She can be reached at