CAÑAS, Guanacaste – Riding in the passenger seat down the dirt roads of Verdero de Cañas, José González, or “Dago” as he is known around town, points out the houses where the other sick people live.
José Manuel Calvo – a man seeking a kidney transplant – stands on the corner, his son tugging at his shirt. Down the street, Manuel Camacho limps out of the field worker’s bunkhouse, coughing, just back from a hospital visit. Iysabel López lives in the stilt house next to the irrigation ditch, and he takes the same medicine as his brother Juan used to. Juan died at 49.
All of these men, including Dago, are under 55. All of them have worked on the country’s largest sugarcane plantation, Ingenio Taboga. All of them will likely die from kidney failure.
“There are more,” Dago says. “I just don’t know where they all live.”
Chronic Kidney Disease (CKD) plagues more than 400 people in the Cañas area, an agricultural town 166 kilometers northwest of Costa Rica’s capital, San José. Most of the afflicted are men between the ages of 20-55, and almost all of them worked the sugarcane plantations or some other job as field hands. In Cañas, the disease has a rate 18-20 times higher than anywhere else in the country. Two months ago, 15 people died from kidney failure in the same week, including two people in their early 20s. There is no cure.
The agricultural workers affected by the disease have largely remained quiet about the problem, and many have continued working to support their families.
Their reticence has been a contributing factor in a growing problem that now threatens agricultural communities across Central America and also in Sri Lanka and India, leading doctors and scientists to label CKD an epidemic. The causes of the disease have remained elusive, but the number of patients continues to grow along with the list of patients requiring kidney transplants. In Guanacaste, the northwestern province that includes Cañas, hospitals are struggling to treat the incoming floods of patients, and the transplant list in Cañas alone is 40 people long. These patients are all in the final stages of the disease and without a new kidney, they will die.
The making of an epidemic
Since its discovery, kidney disease has widely been considered a disease for the old, the overweight and the out of shape. Only in the late 20th century did the disease creep up in parts of the rural third world, where it silently afflicted agricultural workers for nearly three decades, until the problem became too grave to ignore.
Data suggest that Central American farm workers have suffered from CKD since the 1970s, but it wasn’t until the early 2000s that clinicians began to notice an influx of young, otherwise healthy men to hospitals in Central America. By then, the disease had already taken hold, and the dead and dying numbered in the thousands.
“This epidemic emerged in rural and sometimes remote areas at a time when there was less access to specialized medicine in such areas,” said Catharina Wesseling, a researcher with the Work and Health Program of Central America (SALTRA). “It is a slow disease, a chronic disease. It was simply not so evident in the beginning.”
Today, an estimated 68 percent of men in southwestern Nicaragua have some form of renal deficiency. In El Salvador, kidney disease ranks as the country’s third leading cause of death, and preliminary studies in Guatemala and Costa Rica show similar upward trends in CKD.
Similar outbreaks have cropped up in other parts of the world. In Sri Lanka, 8,000 people suffer from the same kidney disease wreaking havoc in Central America, according to the World Health Organization (WHO).
Although they are suffering thousands of miles apart, those with the disease in Central American and Sri Lanka share a strikingly similar profile. The disease in these countries primarily affects young men and agricultural workers, and seems to be exacerbated by hard work.
Researchers also found that in both locations, the specific kind of kidney damage people suffered suggested that dehydration, and in some cases toxic poisoning, might be the culprit.
What’s causing the disease?
It’s a typical Friday at the Cañas Hospital’s dialysis ward. Three nurses run around carrying bags of fluid and emptying metal bowls as they slowly fill with toxins that the patients’ failing kidneys can no longer filter.
Dago González is among them. It’s 4 p.m. now, and like the others, he’s been in the ward since 7 in the morning, a routine he’s been through four to six times a week since January.
Dago was diagnosed with renal deficiency last July, but the first time he could really feel that something was wrong was at the beginning of the last zafra, or sugarcane harvesting season, when he was out in the fields with a fertilizing machine. There was a pain in his legs and his feet felt swollen. He remembers the hot sun overhead, then waking up on the ground, then again in Liberia Hospital hooked up to a dialysis machine.
Dago’s story is not unusual. He and the other three men in the ward that day, along with almost all of those suffering from CKD in Central America spent most of their lives working on sugarcane plantations.
Last November, 50 health experts from 15 different countries converged on Costa Rica in order to begin uncovering the root of the mysterious disease. The workshop’s results are laid out in a 255-page document, with 17 possible causes and dozens of ongoing studies. No one knows for sure why the workers are dying, but heat stress tops the list of possibilities.
“When you look at heat stress there are two major factors, the climate and the metabolic energy required for an activity,” said Jennifer Crowe, a SALTRA researcher. “When we compare the metabolic load for cutting sugarcane to other agricultural work, the load is much higher for sugarcane.”
The research shows that isolated heat stroke incidents are not linked to CKD, but chronic heat stress and dehydration caused by working conditions are. According to Jorge Herrera, the company doctor for Ingenio Taboga, heat strokes are the most common occupational hazard for the company’s workers. In his experience, if a field worker has too many heat strokes, it can lead to renal deficiency.
From an oversized chair in his air-conditioned office, Ingenio Taboga’s Human Resources Director Carlos Barboza flatly denied that work in the sugarcane fields causes kidney problems.
“Some of these guys just don’t take care of themselves,” he said. “There are external factors that we can’t control.”
Roy Wong, an investigator for the Costa Rican Social Security System, known as the Caja, says patients’ habits at home can become a factor, but on their own do not seem significant. Alarmed by the high rates of the disease in Guanacaste, Wong and a team from the Caja have been researching possible causes of the disease since last September. “Because the disease does not affect many women, we are looking for a behavioral factor that has to do with being a young man,” Wong said. “That may be drinking unadulterated, contraband liquor, or it may be working in agriculture.”
For Wong and a host of other researchers, frequent use of non-steroidal anti-inflammatory drugs like ibuprofen is another potential contributor.
Though Barboza has heard that heat is a possible problem, he says the area’s exorbitant CKD numbers are the result of high arsenic levels in the town’s water. He isn’t the only one who thinks so.
Since 2009, scientists have warned the public about arsenic in wells throughout the Cañas area. Tested wells have shown arsenic levels as high as 136 micrograms – the WHO’s recognized level for safe drinking water is 10 micrograms.
Despite pressure from the community and an order from Costa Rica’s Constitutional Chamber of the Supreme Court to President Laura Chinchilla to solve the problem, the country’s Water and Sewer Institute (AyA) has denied responsibility and promised rate hikes if it must decontaminate the water. With CKD-related deaths mounting, though, community groups are increasingly concerned about arsenic.
“They say there are multiple factors,” said Mainor Picado Camareno of the People’s Voice Association of Bagaces, “but even if there are thousands of variables, here we have one. Arsenic is a dangerous poison. It’s a carcinogen. These people are dying and it is their fault.”
Rebecca Laws, a doctoral student at the Boston University School of Public Health, is currently analyzing data from when she studied arsenic levels in Nicaraguan sugarcane workers. The study found that workers with the highest levels of arsenic in their urine also had the lowest levels of kidney function. There is also some evidence that many CKD hotspots in Central America have problems with arsenic contamination.
Other factors, however, have been deemed more relevant than arsenic on the list of possible causes.
“Arsenic is not generally recognized to cause kidney disease,” Laws said. “We think that if arsenic is the cause, it is probably not the sole cause, because then we would expect that men and women would be affected equally.”
Also on the table as potential causes are pesticides, STDs, genetics, and lead and mercury poisoning, all of which could be combining with other factors to create a perfect storm for kidney failure.
“It’s very unlikely that it is just heat,” said Wesseling. “Some people think it’s arsenic. We think maybe it could be heat with arsenic, but it is under-studied. There is still a lot of research to be done.”
Research requires funding, and funding requires outspoken people to create awareness and spearhead campaigns. Poor, immigrant sugarcane workers in a tiny town far from Costa Rica’s capital don’t hold much sway.
Those affected have little power
Every year in late July, Guanacaste holds its annexation festival. Like most Costa Rican fiestas, there are carnival games, rides, dancing and meat on a stick. At this year’s festival there were also massive protests.
“Guanacaste does not only exist on July 25,” read one sign. Another said, “Guanacaste: Victim of bullying for 189 years.”
In addition to protesting the lack of infrastructure, poor health care and uncorrected earthquake damage, the Guanacastecos were decrying contaminated water and high rates of kidney disease. But back in Cañas, the men keep working in the fields, the same way that they always have, even when they are sick.
“The people affected by this are some of the poorest in the area,” said a doctor at the Cañas Hospital who asked to remain anonymous. “They struggle to manage this illness.”
In Costa Rica, sugarcane harvesting is largely immigrant work. During zafra each year, Ingenio Taboga busses in sugarcane cutters from Nicaragua. Many of them return every season to work, while some of them permanently relocate.
Costa Rica has socialized health care available to all citizens, but immigrants only qualify if they hold down a job and are put into the system by their employer.
“The doctor said my defenses are low, but I’ve kept working,” Camacho said. “It costs $10 for me to get to the doctor even with insurance. If I stop working, I don’t have social security and it costs even more.”
For men like Camacho, the situation creates a Catch-22. In order to manage their condition, CKD patients need to make regular doctor visits, take medication and stop working. But if they stop working they will no longer be able to pay for their health care.
Those who do make it into the health care system often don’t follow their medical regiments until they reach the later stages of the disease and experience symptoms. According to doctors at the Cañas Hospital, it’s difficult to convince a hardened farmworker who is in no pain of the seriousness of his ailment.
It’s also difficult to secure government health resources in rural areas. The Cañas kidney and dialysis department was formed two years ago because of the high demand for care in the area. In those two years, only one person has ever gotten a transplant.
“There is inequity in delivery of health care, since renal replacement therapy is mostly not available for poor people with CKD in Central America,” Wesseling said.
Back in Verdero, the sun is beginning to sink towards the horizon. It’s nearly 4 p.m., and clusters of sugarcane workers are leaving the fields. Dago points still to more homes, with more sick people.
They don’t all know Dago personally, but they know of him. When he introduces himself, they try not to look at the bulging bandage under his shirt, where the permanent catheter pokes out of his stomach. It’s not something they are used to seeing.
Dago’s concern for his disease is a rarity around here. He knows things like the names of the pills each person is on and which hospitals they should go to if they don’t have insurance. He gives advice, but doesn’t seem to expect that it will be followed.
Others seem resigned. Some can’t read the documents in their medical files, some have been turned down for medical pensions repeatedly and don’t know why. Even with all of his knowledge about his own condition, Dago can’t think of any way to change it.
“I might put something out on the Internet about a transplant,” he said. “You never know. Besides that, there really isn’t anything that I can do.”