Regular readers of this blog have probably noticed the attention with which I am following the emergence of a new disease in Central America, called CKD or Chronic Kidney Disease. The disease has caused devastation in some rural communities, particularly in both Nicaragua and El Salvador. What is distinct is that it particularly hits men, not women, especially those employed in the sugar cane industry. But the evidence for this is somewhat contradictory, as men employed in other physically demanding jobs also seem to be falling ill with the condition.
There have been a wide array of possible causes suggested for this particular illness. The most common -particularly in the region- has been that pesticides are the underlying problem. Certainly many workers believe this to be the case. This certainly seems plausible, given the fact that some pesticides are used that are illegal in North America. But while this is a serious issue, I have doubts that this is the cause of CKD, for one reason. Why now? Pesticides have been abused in the region for more than fifty years. Why would they be causing such a terrible crisis now? And why are some people working outside of agriculture also being affected, albeit at much lower numbers?
Recently Costa Rica has announced a new study to explore the factors behind the illness. The International Consortium of investigative Journalists has a beautifully done series on this disease, including a multi-media presentation on the illness. In their most recent article, they also describe how the sugar cane industry is responding by providing hydrating liquids for the workers to drink. This is obviously beneficial. But as a medical historian, who specializes in Latin America, I am doubtful that this will cause a major impact on CKD. Sugar cane was the crop that gave colonial Brazil its wealth, that defined the slave industry in Haiti, that dominated the Cuban economy and horrified Castro. Over five hundred years countless men and women have toiled in the cane fields. Anyone who has traveled in Northeastern Brazil or rural Cuba, and seen the endless fields of cane, has a sense of its omnipresence. Yet I’m not aware of anything resembling CKD in Brazilian records, despite appalling abuses of cane workers. I don’t know the Caribbean literature in any depth. But if it had been a past problem, we would have realized that by now. While working conditions for cane workers are poor, they are still better than those of the slave economies that defined cane production in much of the region over centuries. It seems unlikely that dehydration alone can explain the emergence of this new disease. The question is not only why now? It is also why there? There are many other regions -in particular Northeastern Brazil- where people suffer from the widespread use of pesticides and long days of backbreaking labor in the cane fields in the heat. But CKD is not present, or at least is not being reported. Something has changed. And it has changed in Central America but not elsewhere. The current hypotheses about CKD have not sufficiently recognized this.
As someone who wrote a book about HIV in Latin America, this all sounds too reminiscent of the early years of HIV. I spent time in Brazil, Cuba and Mexico talking with doctors and people living with the virus. When the virus first emerged it appeared in Africa, but it was not diagnosed there. It was only when it spread to the United States that people recognized it as a discrete entity caused by an infectious agent. To date, CKD has not received either the attention it merited, nor has their been a broad enough exploration of its possible causation. One possibility is that there is a new infectious agent. There are problems with this idea. Why would it impact men, and particularly men in this industry if a virus or other agent was behind the illness? I don’t know the answer to this question. But something new is happening in Central America, and researchers will only be able to begin to address this question when they understand what a break with the past this disease represents. So either something has profoundly changed in the work environment -which we haven’t yet realized- or there is another factor causing the disease. I would love to see some serious epidemiological work done to rule out this possible hypothesis. And I would hope that regional governments would be inviting assistance from both the World Health Organization and the U.S. Center for Disease Control. Whatever is happening in Nicaragua, El Salvador Costa Rica and elsewhere is causing appalling suffering. And until the cause is found, nobody can know if it may spread. This disease merits high-level funding, research and attention. In its scale, it is the most serious emerging disease in the world today.
One last thought. CKD or chronic kidney disease is a term used globally for the symptoms associated with disorder. But the disorder in Central America appears distinct, in its geographical extent and occupational focus. Perhaps it is time for a new name, to recognize how unusual this illness is, and to help attract global attention? I would suggest Emergent Kidney Disease, or EKD, to emphasize the apparent novelty of this illness.
Are you interested in health in Latin America. Click here to see my book on the AIDS Pandemic in Latin America.
Professor Shawn Smallman, Portland State University
Image of sugarcane workers in Puerto Rico from the Library of Congress, at the Everystockphoto website.