A chronicle of thousands of ignored deaths

Chronic kidney disease is a pressing public health issue that’s been affecting, even killing, thousands of sugarcane workers in western Nicaragua for many years. Neither the powerful Pellas Group nor the Ortega government is giving the issue its proper attention. So much silence, so much forgetfulness, so much acceptance of this tragedy is shocking.

Carlos Salinas Maldonado / Francisco Javier Sancho Mas

In May, once all the sugarcane harvest is in, there’s a contest in the Central American and Caribbean sugar refineries to see who obtained the most raw material for processing sugar, rum and biofuel. In Chichigalpa, Nicaragua, a prize is awarded to the two cane cutters who accumulated the most tons: over 2,400 and 2,300 last year. The prize was a house for each one, valued at $6,000.

That’s a good moment, but it hardly compensates for the fact that on Nicaragua’s Pacific Coast region, a mysterious kidney disease epidemic is killing the young men who work in the cane fields. Their lives and deaths, and those of their families, read like chapters in an old tale of inequality and exploitation, quite out of place for the 21st century. A strange silence hangs over this epidemic, as if it isn’t a matter of life and death. What and who is behind all this neglect?

Flor de Caña and the cane workers

In Managua, parties start at any hour of the night. Still strewn with debris from an earthquake that destroyed the capital city decades ago, hazardous and with a latent beauty that’s never seen; this city doesn’t sleep. Franz Galich (1951-2007), the Guatemalan writer who worked and died in Nicaragua, named it “Managua, salsa city.” In the bars and nightclubs, the same scene repeats itself: a waiter approaches with a bottle of rum and places it in the middle of the table. The unmistakable label for many years was an oval drawing of an old railroad flanked by towering royal palm trees, and in the background the silhouette of volcanoes. It was the image of the entrance to San Antonio, the country’s largest sugar refinery and plantations, located about 80 miles northeast of Managua and owned by the Pellas family, originally from Italy but in the country since the late 19th century. It’s here that the raw material is grown for processing the Pellas’ flagship product: Flor de Caña slow-aged rum.

Although some people prefer to sweeten it further with Coca Cola, connoisseurs drink Flor de Caña on the rocks with true patriotic fervor. It’s considered one of the best high-quality or “premium” rums in the world. Along with sugar—almost half the country’s sugar production is also in the hands of the Pellas family—it’s one of Nicaragua’s important exports, a limited list of products on which gold, coffee and beef are still the most prominent, virtually the same list as at the end of the 19th century.

At those same pre-dawn hours, over 2,000 men are at the San Antonio refinery getting ready to cut cane. It’s harvest time. In those buildings, after blood tests, some will find out that they won’t be going back to work the next day and that they’ll die young if the strange epidemic impairing their kidneys can’t be halted. Round back, in their squalid homes next to the cane fields, all they have left is a life marked by stories worth hearing but that nobody who could do anything about them wants to hear.

A billboard at the turnoff to Chichigalpa, where the San Antonio refinery is located, announces the “Flor de Caña tour,” which the company offers to tourists and distinguished visitors, most recently the Miss Nicaragua candidates. The tour of some of the refinery’s buildings doesn’t include the cane fields, where thousands of men are toiling, bathed in sweat and grime, most of the time under an excruciating ambient temperature averaging over 97° F, exacerbated by the practice of burning the areas of the plantation the night before they’ll be harvested. Humidity can reach 70%.

The dry season is harsh in this part of the country and, instead of alleviating the heat, the wind makes the dust-filled air unbreathable. At the entrance on this side of the refinery, it’s not unusual to find police, even riot police, and groups of workers—some already with advanced symptoms of the disease—who are demonstrating, sometimes blocking the entrance, and carrying placards on which they’ve written their demands to the company and the government.

In January 2014, a group of sick ex-employees was savagely attacked by the National Police while blockading the entrance to protest the unwillingness of the company and governmental authorities to engage in dialogue about their long-standing compensation claim for what they considered work injuries. A 14-year-old boy, Ignacio Balladares, was wounded in the repression, shot “in error” by a police officer who mistook him for one of the workers. He’ll live with a bullet in his head for the rest of his life. Several workers were wounded during the skirmish and one died: Juan de Dios Cortés, a 48-year-old former day laborer during the harvest who had kidney disease. He was brought down by another police officer who shot to kill.

CKD is a death sentence

Chronic renal insufficiency, better known as chronic kidney disease (CKD), occurs when the kidney loses its ability to filter and eliminate waste products from the blood. Because these former workers have limited resources with which to cure themselves, a diagnosis of CKD is usually considered a death sentence. As the disease progresses, dialysis is needed and ultimately, a kidney transplant. Very few manage to get either before dying. In Nicaragua the approximate cost of one dialysis session is $150 and patients typically require three sessions a week. A kidney transplant costs about $14,000, and that’s if a suitable donor is found. It isn’t surprising that Nicaragua, the poorest country on the continent after Haiti, has very low dialysis and kidney transplant ratios, despite one of the highest ratios of renal patients in Central America.

CKD causes the afflicted former sugar workers to suffer a bitter, slow and painful death preceded by frequent vomiting, inflammation of various parts of the body and extreme weakness. According to the limited scientific studies on the subject, the disease is caused by a combination of both occupational and environmental factors. Previously, it was impossible to ascertain the relative extent of the occupational factors with scientific certainty, but it’s finally been proved that they are the most important.

Those who have no doubts about this—and never have had—are the men demonstrating at the entrance to the San Antonio refinery. They believe, feel and know that the main causes of the disease that leaves them without kidneys and life are right there in the cane fields. And they complain that the responses from the company and the government have been suspiciously inconspicuous. In any case, the palliative aid granted to a limited number of beneficiaries is clearly insufficient because they don’t offer solutions to the two big problems plaguing their families: illness and poverty. Resolving them requires a costly level of responsibility that neither the company nor the government seems to want to or can assume.

A pressing public health problem

Records of mortality from CKD are confusing because the magnitude of the problem only began to be considered in the last decade. The Pan American Health Organization (PAHO) reckons there were more than 20,000 deaths in four years, over 3,400 of them in Nicaragua. In Chichigalpa alone it’s estimated that practically half of all adult male deaths are due to CKD, with a rate of 95 per 100,000 inhabitants. Most of the deceased were temporary sugar harvest workers and many contracted the disease before reaching 30 years of age. According to ASOCHIVIDA, an organization comprised only of San Antonio’s former cane workers who suffer from CKD, the epidemic killed 1,196 people between 2009 and 2013. They showed us data that only counted deaths recorded among the association’s members.

PAHO has alerted Central American governments to the gravity of this deadly disease. In a concept paper in June 2013, it warned the region’s health authorities that “this type of chronic kidney disease is a pressing and serious public health problem given its high incidence, prevalence and mortality rates, as well as the unmet health care demand and the burden it represents for the families, communities, health systems and society as a whole.”
PAHO recognizes that CKD imposes a high financial burden on Central America, not only because of the thousands of lives lost, but also because it would require an enormous investment of public funds to establish improvements in health services, skilled human resources to deal with the disease, and treatment and improvements in the living conditions of those affected.

Central America’s governments—excepting Nicaragua’s—have taken a first step in recognizing the gravity of the epidemic. On April 26, 2013, the health ministers of the Central American Integrated System met in El Salvador and signed what they called the “Declaration of San Salvador,” in which they pledged to “urgently promote” measures to prevent the disease. The Ortega government’s disinterest was eloquently demonstrated: it neither participated in this meeting nor signed the document.

A public health mystery

What’s happening here in Nicaragua and in other agricultural areas along Central America’s Pacific Coast is still largely a mystery, at least so far. Countries with similar climatic and geographic conditions and significant sugarcane processing, such as Brazil and Cuba, don’t have these high indices of the disease, much less of mortality. Similar levels have been observed in other countries, though, such as Sri Lanka where investigations by their authorities categorically lay the main blame on pesticides.

Among the first voices of alarm in the medical community was that of Salvadoran Doctor Ramón García Trabanino, who was surprised in 2000 when in just one hospital in his country over 200 patients started having chronic dialysis treatment. He quickly found that most of them didn’t have the disease’s traditional factors and causes known throughout the world: diabetes, hypertension and aging in both men and women. Here the patients were almost exclusively young men, mostly agricultural workers on Pacific Coast plantations. In his study published in 2002 in the Pan American Journal of Public Health, Dr. García stated that his research permitted “suspicion of a relationship with occupational exposure to insecticides or pesticides.” The conclusion of his study was that “further research to confirm this hypothesis” was needed.

Men in Chichigalpa rarely notice the symptoms of the disease until it’s at a very advanced stage. It’s also worrying that high levels of renal damage have been discovered even in adolescents that haven’t yet worked in the cane fields. In just one year there were over 2,000 patients with kidney disease in the municipality who would ultimately need chronic dialysis treatment and transplants.

Given the alarm caused by CKD mortality in the region, PAHO’s directing council meeting in Washington in October 2013 urged the authorities to confront this drama with all due force and urgency because “the right to health is enforceable even in situations of poverty and with an elevated burden of disease.”

SER: A triple business

The 2,000 men who harvest half of San Antonio’s cane fields with machetes—the other half is cut mechanically—contribute to what was always a very profitable business. But the Pellas cane operations have now tripled in value because they aren’t any longer limited to producing sugar and rum; some of the energy distributed to the country is produced by burning sugarcane bagasse. The business group also now produces and exports ethanol, enabling it to expand the business even further when the market price is sufficiently attractive. That’s why Pellas decided to amalgamate the sugar refinery and rum company under the acronym SER (Sugar, Energy, Rum), which summarizes the trio of businesses obtained from sugarcane.

The United States gets nearly 25% of its sugar imports from Central America and has shown repeated interest in the region’s ethanol production. Venezuela has been another major buyer so far. With this bright forecast the Pellas Group got World Bank funding to expand its sugarcane production.

Only one horizon: Cane fields and volcanoes

Besides the cane cutters, the company employs a further 7,000 people in various other tasks required during the cane harvest. In a community such as Chichigalpa, this means that most working age men and women—i.e. excepting only children and the elderly—are dependent on cane fields that haven’t stopped producing sugar since the end of the 19th century when the first Pellas came from Genoa and founded his own empire here.

Although Chichigalpa was one of the first municipalities to have schools, the level of schooling is extremely low, and this in a country in which the quality of teaching in public schools is among the worst on the continent. Non-attendance at public schools by both children and teachers in Chichigalpa is common. Poor education, lack of basic services and extremely poor housing conditions have ended up a kind of norm here, for both the residents and those who make use of this workforce for temporary labor. Cane fields are the only sight on the horizon surrounding Chichigalpa’s communities. Cane fields and volcanoes.

Occupational factors among the causes of CKD

The alarm generated by health professionals, the media and workers’ collectives about the impact of sugarcane workers’ kidney disease led the World Bank to help finance a somewhat more ambitious study of the problem. Nicaragua’s sugar industry, mainly the Pellas Group, was responsible for the other part of the funding. It took place between 2009 and 2012 and was coordinated by a team from Boston University’s School of Public Health. The researchers, led by Dr. Daniel Brooks, analyzed 284 sugarcane workers in Chichigalpa. A preview of the study initially pointed to the epidemic having a “multi-causal” cocktail, which could range from the residue of pesticides used in the past to excessive working hours under conditions of extreme heat, dehydration, bad practices or height above sea-level. The study is still identifying the causes more precisely.

In early February 2015, Boston University published a new paper on its findings in the International Journal of Occupational and Environmental Health called “Changes in kidney function among Nicaraguan sugarcane workers.” There they state for the first time that occupational factors could be linked to the deadly epidemic. The study shows that field workers are at greatest risk of deteriorating kidney function during the harvest season compared to those—factory workers and drivers—who don’t work in the field. This suggests that reduced kidney function is associated with field work, although not all field workers were equally affected. The conclusions state: “The decline in kidney function during the harvest and the differences by job category and employment duration provide evidence that one or more risk factors of CKD are occupational.”
There are many causes
When we asked Dr. Brooks if any one cause predominates over the rest, he told us: “One of the strengths of the study was that it enabled us to assess kidney function by type of work. Most previous studies described kidney function by industry (sugarcane, mining, fishing, etc.), but quantifying by type of work within an industry (cane cutter, irrigator, pesticide applier, etc.) provides much more information, enabling stronger interpretations. The fact that kidney function is reduced in the majority of the seed cutters, irrigators and cane cutters, compared to factory workers, suggests that exposure to the conditions in the field work are affecting kidney function.”
Nonetheless, Brooks said new studies are needed to determine the exact causes of the epidemic. He explained that the results of this study provided evidence that one or more risk factors are occupational, but because the disease is probably multifactorial, other contributing factors could be occupational or not. “It’s difficult to determine the weight and importance of these exposures, because we can’t confirm which specific ones are causing the disease.”

Then why do we go in healthy
and come out sick?

Oriana Ramírez is from Madrid and participated in the work coordinated by Brooks. She said that one of the hardest things to explain to the community at first was that they had no scientific proof that San Antonio’s cane fields were the direct cause of CKD. Most of the men who are going to die were dissatisfied and retorted with a line of reasoning that the researchers still haven’t been able to answer scientifically: “Well then, why are we healthy when we go there to work and sick when we come out?”
In 2015 the university team returned to do three more studies, again coordinated by Dr. Brooks. And again the sugar industry financed a part, leading some people to question the impartiality of the results. They reasonably suspect that no one would pay to confirm that they’re guilty, quite the opposite. However, the most important workers’ collective has given its approval to these studies.

The same criticisms arose when they were about to undertake the first study. At that time, Ariel Granera, a former politician and diplomat and now the Pellas group’s communications director, told us: “Someone has to pay for these studies and it won’t be the workers.”

In response to similar concerns voiced by the Nicaraguan Human Rights Center (CENIDH), Granera reminded it that the company “develops important projects to support the communities around the company, such as building and repairing schools, electrification and sanitation work, making parks, donating school supplies, free medical programs… The San Antonio sugar mill invests over $5 million a year in its social responsibility policies.”

They cut up to seven tons a day

The sugarcane cutters say their wages are calculated on the tons of cane cut by machete, as close as possible to the base of the stem. Each worker cuts an average of five to seven tons a day. During the latest sugar harvest, the refinery determined to reduce the time taken to bring in the cane, because the cane loses sugar content with every minute that passes. The cane cutters compete, spurred on by the incentive of the final prize... or simply to earn a wage that doesn’t even cover their families’ most basic needs.

Brooks’ team of researchers observed that, according to the US Occupational Health and Safety Administration, the cane cutters should rest 45 minutes for every 15 minutes of intensive work in the extreme conditions in which they work, so that the body doesn’t suffer excessively. This isn’t realistic for Nicaraguan cane cutters. In the San Antonio sugar mill, says Granera, “the workdays have been reduced to no more than eight hours and the company provides sufficient hydration, as well as on-site monitoring and care for its workers.” About the rest periods…not a word.

“I just want to die in peace”

We visited the neighborhoods where many of those affected by CKD spend their lives. Hazel is a 24-year-old resident of the “Septic Sinkhole,” the name they’ve given to a ramshackle settlement of hundreds of slum dwellings close to the mill, grouped around a septic sinkhole. The name says it all...

She guided us through narrow lanes. It was getting dark and we could see the reflection from the sugar mill’s lights and then the glow from the burning cane fields. The stench of sewage water running through the dusty streets between the houses accompanied us relentlessly. We tried to avoid walking in the black muddy rivulets. Hazel took us to another neighborhood in the same condition. A young man called to us from inside a house. It was impossible to make out his face. “House” really doesn’t describe the tiny space between plastic sheeting and twigs where he lives with his 20-year-old wife and two children—aged 3 and 1—about to go to sleep while a couple of pigs grunt as they root to find space under the bed on the wet dirt floor.

The man knew we were journalists and were asking people in the communities around the sugar mill about the epidemic. His name is Héctor Danilo Zapata and he’s 30 years old. He has worked in seven sugarcane harvests, but his contractors only recognized him for three. It’s rumored that some subcontracts don’t account for the real number of workers to save on social security payments. Héctor took out a plastic bag, where he kept important papers to protect them from leaks and dust. Some of his papers were test results for creatinine, a waste product that appears at high levels in the blood when the kidneys aren’t functioning. When the result shows over 1.4 mg/dl, the disease is very advanced. Héctor showed us one of 3.9 mg/dl and another of 5.9 mg/dl.

“They told me in the sugar mill that I’d got it and then just let me go. I didn’t get any support from social security or from the company. They told me I had no rights because I hadn’t made the minimum number of weekly contributions.” Héctor has had to work in the cane fields of other companies that turn a blind eye to sick workers. “But I’ve only been three times lately because I’ve got no strength; I just want to stay in bed the whole time.”
He tells us that the most he can earn in these circumstances is C$600 every fortnight—about $40 a month. He spoke with the directness of a young man full of sorrows. His voice, his eyes in the dim light from a single flickering light bulb, the situation in which his family lives, all leave no trace of doubt. These men aren’t lying. They’re going to die and no one seems to want or be able to prevent it. Héctor wants “to die in peace.” “What do you mean by that?” we ask him. “That they at least help my wife and my children so they aren’t abandoned.”

We hear the same story in several houses in the community. “I’ve got it” is the usual phrase used by workers who’ve been diagnosed with CKD. In the best of cases, a pension—if the worker can show he’s worked the number of harvests stipulated to have the right to a pension—comes to the equivalent of $200 a month. In the best of cases. According to official figures, the basic cost of living in Nicaragua is twice that. Everything here demonstrates an old, murky story of exploitation and neglect. It’s hard to balance the story of our eyewitness’ facts and evidence from an impartial or objective journalistic standpoint when the magnitude of the disparity is so evident.

No more room in the cemetery

A megaphone announces the wake for someone new who has died. Hazel tells us that every day the same car passes by announcing the dead. “Day and night. It’s horrible.” They always say the name and often the nickname. The one today died in the San Antonio sugar mill. Not from CKD this time, but by electrocution while doing some repair work.

If Juan de Dios Cortés, the man in last year’s demonstration, hadn’t died from police bullets, he would have died from CKD, like so many of his former colleagues. So very many that the mayor of this municipality, from the ruling Sandinista party, had to open a new cemetery, as the old one getting full. And because the families of the deceased are so miserably poor, the mayor—who also has family members who were victims to the disease—has a policy of giving his neighbors a last act of charity: a plot of earth for their graves.
We went to the old cemetery and walked around those graves. The dates on the crosses testify to the magnitude of the drama. Most of them don’t span four decades. Very few lie beneath cement slabs; others only covered in earth under crosses with a name, or not; plastic flowers, or not. “We’re running out of men,” exclaims a woman from another community close to the sugar mill called “The Island.” With all the deaths, she explains, it’s become popularly known as “Widows’ Island.”

The night is clear but moonless, so there’s no way of knowing where to step to avoid falling down or sinking into the mud. The light from cell phones helps us and Hazel also warns where the puddles are, as she tells us that she’s worked in the sugar mill “in everything you can work in and always for a pittance. Why did I quit studying and get in with men!” she laments. She got pregnant, twice, when she was very young, but the man took off and the sugar mill provided the only way to support her family; albeit in poverty.

The taboo word: Compensation

Since 2007, Daniel Ortega has had hundreds in millions in Venezuelan aid to finance a wide range of social projects, criticized by the opposition as “perks” or “crumbs.” He’s also used those resources to build a network of companies managed by some of his associates and family members. We still don’t know whether they’re public or private. Although he exercises absolute influence over the country’s key institutions, he seems to have a lot of popular support. “During the three previous governments we received nothing. At least, Daniel and la Chayo [his wife, Rosario Murillo] remember us and give us gifts once in a while,” a domestic worker in Managua told us.

Ortega doesn’t give interviews to the national media nor does he usually explain his decisions. His agenda isn’t public, but Murillo is in charge of the Ministry of Communication and broadcasts a daily report about the government’s actions. She tirelessly works at publicizing the merits of “a revolution” that she brands with three adjectives repeated in the street like a mantra, sometimes seriously and sometimes derisively: “Nicaragua: Christian, Socialist and Solidary.”

On large billboards throughout the country, the ubiquitous image of the former revolutionary leader is always encircled by a spectrum of bright colors dominated by fuchsia, Murillo’s favorite. It seems like a constant electoral campaign of the only candidate. The latest is the announcement of a pharaonic project that has dusted off Nicaragua’s old demons and utopias: the construction of an interoceanic canal to compete with Panama’s. Recently, the journalist Jon Lee Anderson extensively addressed the issue in a report for The New Yorker, which raised serious doubts about the materialization of this mega-project headed up by a Chinese businessman who emerged from practically nowhere. However, the project is a kind of permit to dream. Immune from the divided and now miniscule opposition, Ortega and those closest to him, particularly his wife, have calculatedly handled relationships with the country’s two great powers: the different churches and the large family economic groups, his enemies in the 1980s.
At the entrance to Chichigalpa there a second billboard equal in size to the one of Flor de Caña rum; it is of President Ortega looking out at an invisible horizon. Could it be that the macroeconomic bonanza is behind the current understanding between this Sandinista government and the entrepreneurial elite? Although the Ortega of today has given his political stance a change of direction, now imbued with religion, trying to mix some former Sandinista ideals with a certain pragmatism learned along the way, the truth is that the self-proclaimed “Christian, socialist and solidary” government has said virtually nothing about the workers affected by CKD. Its silence is particularly notable given the issue’s gravity and paradigmatic nature. Neither the government nor the companies want to hear any talk of a word considered taboo: compensation.

The Pellas empire

In a meeting held in 2013 between the country’s major entrepreneurs and the presidential couple, Carlos Pellas described the climate of understanding between the two sectors as “miraculous.” Praises of a religious nature were plentiful at that meeting.
The lives of Carlos Pellas and his wife Vivian were radically changed by a plane accident, the worst in Central America. In 1989, a SAHSA flight to Miami with 146 people aboard the Boeing 727 crashed into the Honduras mountains. Only 15 people survived, among them Pellas and his wife. He managed to pull her out of the plane before it exploded, but she was very badly burned and underwent numerous reconstruction operations. She currently chairs a foundation that helps children with burn injuries, supported by her husband as another expression of the Pellas Group’s social responsibility. In 2004 she also built a burn unit at the new Vivian Pellas Metropolitan Hospital.

Heir to the family business, the Pellas group today brings together a conglomerate of million dollar businesses ranging from banking to citrus fruit (Pellas owns one of the largest orange groves in the world), electricity distribution, insurance, a bank, computer companies, the distribution rights for brands such as Toyota and Suzuki, luxury eco-tourism, the vast sugar operation, liquor outlets, etc. Carlos Pellas has an office on the top floor of one of Managua’s few tallish buildings [a 12-story blue glass mini-skyscraper] in a city that still lives in fear of the next earthquake. From there you can see the other, more genuine skyscraper that survived the 1972 earthquake and also belonged to his family before passing into the hands of the State. When the Central American magazine Estrategia y Negocios (Strategy and Businesses) singled him out among the most admired businessmen, Pellas declared: “I think I have contributed significantly to the development of the region by creating more than 100,000 direct and indirect jobs… God allowed me and my wife to survive a terrible plane accident, which has changed our lives considerably, increasing our commitment to others, especially the most vulnerable.”

Accustomed to desperation

The men who cut sugarcane for the San Antonio refinery start work very early. Beyond the causes of this disease so many will have ahead of them, we feel that the stories heard in the streets and squalid homes of this community tell an old story whose ending we already know... it never ends. Here announcements of wakes and funerals, and requests for urgent support for the sick and their families are routine. The research will probably confirm what’s already been advanced: that one or more factors of the disease are the occupational conditions in certain sugar mills. But it’s also probable that the demands of families of the deceased, and of the ones who will die from CKD, won’t be compensated.

At least graves may continue to be donated in the new cemetery, but one hopes for a more dignified answer. It remains to be seen if improving the living and working conditions of these communities will have any impact on reducing the epidemic. Although it’s difficult to believe, men here have become accustomed to frameworks of poverty and pain and don’t let them totally burden their lives. Even knowing that their parents died from CKD, they send their children to work in the cane fields and it’s very likely that if the company decides to completely mechanize the refinery work, it will lead to demands that at least some of the sugarcane harvest continue to be done manually. It’s the story of becoming accustomed to desperation.
Those who see them from outside, and those who live within, have also become accustomed to seeing them, prostate on their beds or in hammocks, already with a life sentence in their kidneys, or simply with no future except to live between sheets of cardboard, work in the cane and get sick or emigrate. It’s the life that the sick and dying men, or the child with a bullet in his head, expect in Chichigalpa. What’s so striking, more than a century later, is this silence, which is also customary.

Carlos Salinas Maldonado and Francisco Javier Sancho Más are journalists.

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