It has been about a year since I traveled to Nicaragua with Vision Nicaragua, an organization that helps Nicaraguan students afford college. While we were there, we had a “vegetable race”. There were two teams and each team had to go to the market with a certain amount of money (300 córdobas) and get ingredients to make soup for 20 different families (40 families total). Whichever team got the most ingredients with the money we were given, won the vegetable race. We then walked through the pueblo we had been working with all week and gave a bag with the ingredients for soup to each widow in the pueblo. There were forty widows in this pueblo of 300 people. There were more widows in this pueblo than there were women with husbands. This pueblo was in Chichigalpa, a poor town on the southwestern coast of Nicaragua where there is an extremely high rate of Chronic Kidney Disease (CKD). Many females that have husbands working in agricultural fields become widows at a young age because they lose their husbands to CKD. This past fall I wrote an essay on this epidemic in a GIS (Geographic Information Systems) class where I studied the different factors that correlated such as the number of sugarcane fields in Chichigalpa and the rates of CKD in Chichigalpa compared to other towns. I learned a lot about what the different contributing factors are, but in this essay, I will discuss what I learned about the different narratives surrounding the disease. I will explain the narratives told by the scientific community and the government where they are very formal and take little action on the issue. Then, I will contrast this with the narrative told by the local, affected citizens. The two narratives are very different and they tell you something about who is benefitting from the lack of action being taken on the issue. It can tell you a lot about the power relations in countries like Nicaragua where the government is corrupt and has total control. Lastly, the contrast in the narratives can show you how environmental and health issues are often political. In many cases, those who are in power have the ability to make a drastic change, but instead they put the issue and the people affected by it on the back burner. This is why these people need help getting the attention of their authorities to show them how big of a problem it is and that it needs to be addressed immediately.
CKD begins with multiple factors often called “chistasta” where back, kidney, and urination pain are involved. It is most often seen in younger men who work in trying conditions such as an agricultural field. The disease is defined as “the presence of kidney damage resulting in structural or functional kidney abnormalities”. There are five stages of CKD and it is in the fifth stage where kidney transplants or dialysis is necessary. Often times, the symptoms do not show up until the later stages (Jimenez, 2016, 1-4). Many countries are unable to provide the necessary “stage five surgeries”, leaving patients to suffer and die at a young age(Ramirez-Rubio, 2013).
In countries where there are high rates of CKD, there is a correlation between low socioeconomic status and the disease. This is for multiple reasons that I will explain later in this essay. It is estimated that about 20,000 people have died from CKD in central America over the past 20 years, most of these people being sugar cane workers. The sugar cane business is increasing and doesn’t seem to be going anywhere anytime soon. CKD is now responsible for 75% of the deaths of young men in Nicaragua (McKie, 2017). Furthermore, according to the Institute for Health Metrics and Evaluation, it has ranked #2 in the top causes of death for the past decade. A majority of these CKD patients in Central America are from developing nations where the treatments are less intensive and less effective. With that being said, patients with CKD in developing nations are much more likely to die faster than CKD patients in a developed nation where the treatments are better and the necessary surgeries are available (Jimenez, 2016, 7).
As I had previously mentioned, there are different narratives surrounding this issue. There were two main narratives that I found while researching this topic: the government narrative and the local, citizen narrative. I will first explain the government narrative, which is mostly told through peer-reviewed scientific articles. Many of these scientific articles are similar because they survey a large group of people, come up with the same results, and finish by saying that more research should be done. The scientific community focuses on facts like what contributes to CKD the most and the symptoms of the disease. In many countries, the onset of CKD is caused by chronic hypertension or diabetes (Jimenez, 2016, 54), but in Nicaragua and other developing countries in Central America, the causes typically include extreme heat, repetitive dehydration, self-medication, and chemical exposure (Wesseling, 2016). CKD is considered a multifactorial disease meaning that more than one of these causes has to happen. Just being exposed to extreme heat will not cause CKD. Some of the scientific articles also say that having family members who had CKD puts agriculture workers at an even higher risk. In Central America, sugar cane workers are paid by how much they cut rather than being paid hourly (Little, 2016). This encourages fast-paced, hard work in the sun for long hours with little breaks.
While all sources agree that dehydration is a factor, there is some uncertainty about how it impacts the kidneys. Ramirez-Rubio et al. (2013) conducted a study where she and colleagues interviewed physicians and pharmacists in Chinandega and Léon and saw that they had uncertainties about the dehydration factor. Half of the interviewees believed the lack of drinking water while working in extreme heat was what damaged the kidneys, while the other half believed it was the contaminants in the water that damaged the kidneys (Ramirez-Rubio, 2013). Because of extreme poverty and poor health care, instead of seeing a doctor, many people will take incorrect medication, further damaging their kidneys. The scientific articles that I have been reading do not really discuss solutions to the overall epidemic. Rather, they suggest future research ideas. Keep this in mind when I explain the solutions that the other narrative suggests.
The second narrative that I found to be pretty popular was mostly told by the lower-class citizens of Nicaragua, the people who were affected the most. Out of all the scientific pieces I read, I only found this narrative told in one which was a dissertation by a student who was studying Latin American Studies, not the actual science of CKD. I point this out because, it is the scientists who are solely focused on environmental factors that contribute to CKD while the second narrative focuses on political, economic, and social factors that contribute to CKD. I also want to point out that the narrative that I will discuss from the Nicaraguan citizens does not come directly from them, but rather it comes from reporters and people who interviewed and worked with these citizens. This is important to note because it further shows that these people do not have a voice to speak about the issues they are facing. The only way their problems or concerns get attention is when someone else who has more power comes in and publishes their stories and experiences.
Lower class Nicaraguans are angry because they feel as if the government is not taking enough action on a disease that is killing many young men in rural regions of Nicaragua, leaving jobless mothers to take care of the children by herself without any kind of support. Some Nicaraguans even go as far as to claim the government “is behind” the CKD epidemic. This is because the sugar cane business makes so much money for Nicaragua, that some citizens believe the government is simply not doing anything because they don’t want to the sugar cane business to crash (Lahkani, 2015). A sugar cane worker from Nicaragua who is only 32 says, “Every family here has lost someone, the work is making us sick, but there are no alternatives” (Lahkani, 2015). That is the other “problem” that this second narrative points out, that there are no alternatives. In their culture, it is typical for the woman to stay home and take care of the children while the husband goes out to find work. There are not many other jobs for men who did not go to college, which is a large number in a poor country like Nicaragua. Once a worker is diagnosed with CKD, the agriculture company will let them go because it is illegal to hire a sick person or minor. But men will get fake IDs and continue to work in the fields because they have no other options for work (Lahkani, 2015).
There is even a difference in the stories told about what is like out in the fields. The ISA (Nicaragua’s oldest and largest mill) claims that they provide shade, water, and give the worker’s ample breaks. The workers highly disagree. There was a case where representatives from La Isla came to observe a day in the fields and the conditions looked fine, but when undercover representatives came to observe, they saw no shade, water, breaks, or appropriate clothing provided (Lahkani, 2015).
As I had mentioned earlier, the sugar business brings in a good sum of money for Nicaragua, 5% of its GDP to be exact, and it is only growing (Lahkani, 2015). The country’s government is currently corrupt with a power-hungry dictator (President Daniel Ortega) and his wife as the vice-president. There is a strong tie between the sugar agribusinesses where the businesses support Ortega and he, in turn, supports the agribusinesses. It reminds me of how scientists who are climate change deniers support oil companies who are secretly funding them.
Nicaraguans are fed up with how the government has handled the issue and have taken matters into their own hands. In 2013, there was a protest held in Chichigalpa where they blocked traffic to a major city, trying to get the city official’s attention. Tom Laffay, a staff member of La Isla, an organization that funds research and advocacy for CKD in Nicaragua, was present during the protest and explained how it went from a peaceful protest to a violent riot very quickly. Police released tear gas canisters, hit protestors with riot shield and batons, and arrested 23 people (Laffay, 2013). This occurred in 2013, and while I cannot be sure, I assume there have been multiple protests since then because the epidemic has only gotten worse and the government has become even more corrupt.
Earlier I had pointed out that most of the scientific articles do not offer solutions for the disease. But those who have been directly affected have plenty to say about solutions and changes that need to be made. A clear-cut solution stated by Juan Rivas, a sugarcane worker with stage 5 CKD, is fair compensation for workers and access to medical treatment (Lahkani, 2015). He says that access to medical treatment is a right, and other primary sources say that these are human rights. In Becky Little’s article (2016), she says that workers need rest breaks, hydration, and shade, all of which she claims are human rights. If the government is not going to provide more work opportunities for the men in these rural communities, they should at least provide ample protection in the few job opportunities that they do provide. Lastly, families who have lost a father, son, or any family member to CKD need government assistance in order to survive. As I had mentioned earlier, families really struggle financially once their main source of income has passed away.
“If this was happening in the west it would have been dealt with long ago,” says a kidney expert who follows the epidemic in Nicaragua (McKie, 2017), and he is exactly right. The percentage of CKD in developed countries is much lower and is caused by very different factors like diabetes and chronic hypertension and affects mostly older citizens. CKD has been negatively affecting Central America for half a century now, so why has the government not stepped in? After reading through 10+ articles, dissertations, and news reports, I was trying to figure out what the two main narratives surrounding CKD were. It was easy to say that the local, citizen perspective was one of them and I knew how the other narrative was told, but I wasn’t sure who told this it. It seemed like it was the government and the scientific community, but the more I thought about it, the government hardly tells a narrative about the problem because it doesn’t even seem to be on their radar and they rarely discuss it. The Nicaraguan government knows CKD is killing their people because there have been protests and riots for decades and there is clear proof in dozens of research papers. But this is not an issue of uncertainty where the government does not know how to handle the problem; it is an issue of politics, power, and priorities. The government’s priorities are in building its economy and not in the health of its citizens. It creates a continuous loop that poor communities cannot escape. They have no other choice than to work in these fields and support the sugar business that is taking away all of their fathers, brothers, uncles, and cousins. Almost everyone in the poor communities of Chinandega, Chichigalpa, and León has lost someone to this disease. International actors are stepping in because they have more power and could possibly help the situation, but for now, Nicaraguans will continue to live through structural violence caused by their government.
After reviewing the different narratives that surround the Chronic Kidney Disease epidemic, it is important to address the fact that environmental and health issues are often political issues. To review, the government or scientific narrative is that there are factors like dehydration, extreme heat, and hard work that cause kidney damage, eventually resulting in Chronic Kidney Disease. To them, the solution is that more research needs to be done so that they can correctly identify the main cause of the disease. The lower class Nicaraguan’s who are affected by the issue claim that the lack of attention the government gives to the issue is what has caused it to spiral out of control. They demand to be heard by the authorities and prioritized like any other Nicaraguan. They also believe the government needs to provide more job opportunities for men, better protection for the farm workers, and more assistance to the families who are affected.
Those who are in power for a nation should address the nation’s most concerning issues, but they also have the power to hide or ignore these issues. Nicaragua’s government skews the story about CKD so that they do not have to address it. They would have to make major adjustments in their priorities and put the lives of the Nicaraguans before the agriculture business that makes up the majority of the country’s GDP. This is why we have to lift the voices of those who have less power so that their stories, concerns, and experiences do not get covered up and ignored.
References
Chavkin, S. 2012. “As kidney disease kills thousands across continents, scientists scramble for answers.” The Center for Public Integrity.
Ferarri, R. 2017. “The Silent Massacre: Chronic Kidney Disease in Central America's Sugarcane Workers.” Center for Latin American Studies at the University of Pittsburgh.
Jimenez, KA. 2016. “Risk Factors Associated with Chronic Kidney Disease of Unknown Etiology (Ckdu) : A Study of Patients from an Occupational Health Clinic in Rural Nicaragua.” Dissertation, University of California, Irvine. University of California, Irvine.
Laffay, T. 2013. “Nicaraguan Kidney Disease Epidemic Protest Turned Violent.” La Isla Network.
Lakhani, N. 2015. “Nicaraguans demand action over illness killing thousands of sugar cane workers.” The Guardian.
Little, B. 2016. “Pictures Show the Mysterious Disease That’s Killing Field Workers.” National Geographic.
McKie, R. 2017. “Haunted by the mystery deaths in Nicaragua’s brutal sugarcane fields.” The Guardian.
Montini, G., Alberto E., Silva G.Y., Sandoval D.M., Medina M.M., Giuseppina M., Fabio R., Gianni T., and Fabio S. 2016. "Non-Medical Risk Factors as Avoidable Determinants of Excess Mortality in Children with Chronic Kidney Disease. A Prospective Cohort Study in Nicaragua, a Model Low Income Country." PLoS One 11 (5) (05).
“Country Profiles: Nicaragua.” 2017. Institute for Health and Metrics Evaluation.
Ramirez-Rubio O, Brooks DR, Amador JJ, Kaufman JS, Weiner DE, and Scammell MK. 2013.
“Chronic Kidney Disease in Nicaragua: A Qualitative Analysis of Semi-Structured Interviews with Physicians and Pharmacists.” BMC Public Health 13: 350–50. doi:10.1186/1471-2458-13-350.
Wesseling, C., Aurora, A., Marvin G., Ilana W., Jason G., Norma A.B., Carlos R.J., Ricardo C.R., Richard J.J., and Lars B. 2016. “Kidney Function in Sugarcane Cutters in Nicaragua - a Longitudinal Study of Workers at Risk of Mesoamerican Nephropathy.” Environmental Research 147: 125–32. doi:10.1016/j.envres.2016.02.002.
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