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Unexplained Chronic Renal Failure Epidemic Grows

October 11, 2009

I wrote the following article about the epidemic of chronic renal failure in Central America in March 2007. Since then it has come to my attention that there is a very similar epidemic of renal failure in the North Central, North Western, Eastern and Uva provinces of Sri Lanka. Paddy (rice) growers are mostly affected, with a male to female predominance of 4:1. The prevailing theories about the cause there are cadmium or fluoride toxicity. Unlike in Central America, where the agriculture in affected areas is or was large scale export oriented production, affected zones are  in Sri Lanka are primarily subsistence farming.

Another update to this story is that, with the new FMLN government in El Salvador, the Ministry of Health is being run by public health professionals who are also health activists. They are aware of this problem and plan to investigate possible causes. I am waiting for news about changes in the way the Ministry health services deal with chronic renal failure. More details after my trip to El Salvador in November.

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The unrecognized epidemic of chronic renal failure among export agriculture workers and communities of Central America.

For years in developing nations, international aid agencies and multilateral organizations have defined the health services that are provided to poor communities by what they fund, and by requiring structural changes in government services as conditions for loans. These programs have emphasized maternal/child health, malaria, HIV, tuberculosis, and a few other diseases, with limited input from local beneficiaries or providers into these priorities. But among the consequences of health programs designed by people from outside of the communities they serve is that they don’t address the community’s real needs.

The leading cause of death among adults in the municipality of Jiquilisco on El Salvador’s coastal plain is unrelated to the priorities of aid agencies and the World Bank. Chronic renal insufficiency, not associated with its usual causes, diabetes and high blood pressure, has been diagnosed in 30-45% of men over 30 — and there are few resources directed toward the prevention, early detection, or treatment of this disease. In 2005 a community organization, the Fondo Social de Emergencia (Emergency Social Fund) identified 23 deaths from renal failure. The Salvadoran Ministry of Health counted only one. In the first half of 2006, 12 people (11 men and 1 woman), in a population of about 40,000, died from renal failure.

Chronic kidney disease and renal failure are recognized as a growing problem throughout the world. In most places, this is due to lifestyle and dietary changes that have promoted an increase in diabetes and hypertension. Jiquilisco has experienced this same increase, but the large majority of those diagnosed with chronic kidney disease in Jiquilisco have had neither predisposing condition.

Jiquilisco is located in the region known as the Bajo Lempa (the lower Lempa River). From the 1940s through the early 1980s, people’s main economic activity was growing cotton for export on large plantations. Workers were exposed to high levels of a variety of agricultural chemicals and the shallow water table became heavily contaminated. The highest incidence of renal failure is among former plantation workers.

There is no treatment available for chronic kidney disease in the Salvadoran Ministry of Health clinics. According to Mirian Colindres, the nurse at the clinic in La Canoa, Jiqulisco, they never have ace inhibitors – the high blood pressure medication usually given to preserve kidney function. They rarely have any high-blood pressure medication at all. “For years the aid agencies and PAHO have emphasized maternal-child health, so that is what we have, medicine and supplies for women and children. But men and adults and old people live here too and deserve attention. If a father dies from kidney failure, his children won’t have enough to eat and then we’ll give them vitamins. It would have been better to treat the father.”

Once the illness has progressed to kidney failure, it is almost impossible to get hemodialysis. The Salvadoran Health Ministry has so few machines that new patients sign on to a waiting list – waiting for someone currently receiving dialysis to die.

The alternative to hemodialysis is peritoneal dialysis, a procedure in which the abdominal cavity is filled with dialysis fluid and toxins diffuse through the cavity membrane over several hours. In El Salvador, patients are not given supplies to perform this procedure in their own homes, a common practice in other countries. In any case, most patients cannot afford the extra charges the hospital levies for a permanent abdominal catheter. Instead, they must have their abdomen punctured by a temporary catheter every time they go for treatment – twice a week. Most give up after a few times, preferring to “die at home with the children and grandchildren around.”

Recent studies by nephrologist Dr. Ramon Trabanino and Instituto Municipal de Salud Publica de Barcelona have identified that this epidemic is, in fact, occurring all along the Pacific coast of Central America in areas of current or former export agriculture. These studies contrast coastal agricultural workers with subsistence farmers at higher elevations. In Mexico, Guatemala, Honduras, and El Salvador the results are similar. Men who have worked in export agriculture in the hot coastal zone, routinely exposed to agricultural chemicals, experience elevated rates of renal failure that increase with age. Most do not have the usual risk factors of chronic hypertension or diabetes. In contrast, the men from higher, cooler elevations have normal rates of renal failure.

Sugar cane workers in Chichigalpa, Nicaragua face the same epidemic. 2400 have died of renal failure since the year 2000. This small town is renowned as the center of Nicaraguan sugar and rum production since the founding of Ingenio San Antonio, one of the largest sugar cane plantations in Central America, in 1898. The Pellas family, owners of Nicaragua Sugar Estates, is one of the richest and most powerful in the region, but they have refused to assist their former employees. In fact, the workers were fired when they were diagnosed with the disease.

While El Salvador’s Health Ministry and other governmental agencies have neglected the problem, the community itself has begun to attend to its own needs. Founded by communities in Jiquilisco in the wake of Hurricane Mitch, the Fondo Social de Emergencia de Salud caught the attention of Dr. Trabanino and inspired him to conduct the research described above. He has helped the Fondo to organize low-cost kidney disease screenings, educated effected persons on what to demand from treatment, and has provided appropriate, standard of care treatment to some patients for no cost.

The Fondo is now educating the communities about the causes and prevention of kidney disease – advising farmers not to reuse agrochemicals containers for drinking water, to apply chemicals more safely, to use medications correctly, and to drink enough water to avoid daily episodes of dehydration. They have succeeded in attracting national media attention. The Fondo raises money through international donations and by asking every household to contribute 25 cents a month. Another local organization, United Communities of the Bajo Lempa has sought independent financing for a potable water project without the involvement of the government water authority. They organized work brigades to build a system carrying water from higher elevations so most of the area’s inhabitants no longer have to drink contaminated well water.

In spite of community efforts, the cause of the epidemic is still unknown. There is clearly an association with agricultural work and chemical exposure, but a specific agent (or agents) hasn’t been identified. Since the large growers and chemical manufacturers are controlled by the wealthiest and most powerful families in Central America, it is unlikely that any government affiliated body in these countries would undertake an epidemiologic investigation or recognize the liability of these businesses for their employees or customers injuries. The unregulated use of medicines, the overuse of pain medication, and other factors that cause a reduction in reserve kidney function may also play a role in the process that leads to an individual developing this condition.

Dr. Trabanino has tempered his initial suspicions regarding chemical exposure, and suggests that daily episodes of dehydration while working in extreme heat may be the cause. However, while dehydration has been identified as a cause of acute kidney failure (not chronic renal insufficiency), one would expect other conditions associated with heat and dehydration – heat exhaustion, heat stroke, and kidney stones – to be common if this were the cause. They are not.

Further complicating the picture are cases of men with chronic renal insufficiency who have lived in the area for less than 13 years and who were only minimally involved with agriculture. Mirian Colindres, the nurse quoted above, lost her brother to kidney failure two years ago, and her husband has CRI. They moved to Jiquilisco after the civil war ended and worked in small scale agriculture for only 1-2 years.

Beyond Central America, this epidemic raises many other serious issues:

For workers and their families: Is this epidemic occurring “under the radar” in other export agricultural regions? How can workers effectively demand that the cause be identified and appropriate prevention, screening, and treatment be provided? What other health problems are being caused in these areas by chemical contamination and dangerous working conditions?

For governments, health ministries and public health professionals: Will the epidemic be investigated? Will people receive the prevention, screening and treatment required? Will responsibility be assigned to ensure workers are protected from dangerous working conditions? Will companies and individuals be held accountable for negligence in the treatment of workers and marketing of products? Who will apportion responsibility among the national and multinational chemical and agricultural companies, and the wealthy nation consumers who purchase the sugar, rum, bananas, flowers, textiles and other goods produced with intense chemical inputs in developing countries? Will the multilateral organizations, aid agencies, and funders that claim “improving health” as their mission begin to include local communities in designing health programs?

For more information:

http://Fondosocial-emergencia.webb.be

http://72.14.203.104/search?q=cache:SlQqG6cUxIgJ:www.fluehi-ma.de/allgem/downloads/saludos_26.pdf+%22fondo+de+emergencia%22+lempa+blanca&hl=en&gl=us&ct=clnk&cd=4

http://www.prensalatina.com.mx/article.asp?ID=%7B1CA40CA7-BB2B-4193-92EC-37E91563599F%7D

http://www.elsalvador.com/noticias/2006/05/08/nacional/nac10.asp

http://www.elsalvador.com/noticias/2006/11/11/portada/index.asp

http://www.worldmag.com/articles/7474

http://www.lainsignia.org/2006/febrero/ibe_020.htm

http://hbar.phys.unca.edu/ncur20//abstract_display.asp?id=1867

http://www.scielosp.org/scielo.php?pid=S1020-49892002000900009&script=sci_arttext

http://www.inchem.org/documents/ehc/ehc/ehc119.htm#SubSectionNumber:2.5.6

The studies by Dr. Trabanino on chronic renal disease in Mexico, Guatemala, El Salvador, and Honduras are available from phm(at)turiano.org.


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4 Comments leave one →
  1. October 11, 2011 9:51 pm

    Es una realidad la epidemia de deficiencia renal, no solo en el bajo lempa sino tambien en todas las regiones donde hubo influencia del cultivo del algodon, esto sucedio en otras diferentes regiones de este pequeno pais El Salvador, a pesar de el incremento de los casos en eatpa terminal, el gobierno no hace absolutamente nada para prevenir l;a enfermedad a generaciones futuras, que todavia utilizan agua contaminada por pesticidas utilizados hace 20 anos, por otro lado la red publica de hospitales y clinocas no da abasto para tratar y dar una mejor calidad de vida a los pacientes en etapa terminal.

    • October 12, 2011 8:19 pm

      (English below)
      Gracias por su comentario, Hector. Abajo traduzco lo que escribió.

      Suena que ha tenido experiencia personal con esta enfermedad. Pero desde el cambio del gobierno en El Salvador ya no es cierto que el gobierno no hace nada. En cooperación con dos nefrólogos de Cuba, el Ministerio de Salud ha establecido un programa nacional en salud renal coordinado por un nefrólogo Salvadoreño. Están haciendo estudios sofisticados de la epidemia. En el Bajo Lempa ahora hay una Unidad de Salud Renal que implementa un programa de educación sobre la enfermedad, como reducir el riesgo, y que también cuenta de las medicinas y pronto van a poder hacer diálisis peritoneal. Este programa es un piloto que van a replicar cuando identifican otras zonas afectadas. La Ministra ha levantado el problema con la Organización Mundial de Salud. Todavia no han encontrado la causa pero tengo mucho mas confianza ahora que van a poder hacerlo.

      Otra cosa que quiero mencionar es que la enfermedad no viene del agua tomada. SI fuera la causa, las mujeres tanto que los hombres serian afectadas porque toman el mismo agua. Pero no es asi. 4 hombres estan afectadas por cada 1 mujer afectada.

      Aqui es la pagina Facebook del programa Nefrolempa: http://www.facebook.com/nefrolempa

      English translation
      “The epidemic of renal insufficiency is a reality, not only in the Bajo Lempa but also in all the regions where there was the influence of cotton cultivation. This happened in other different regions of this small country, El Salvador. In spite of the increment in terminal stage cases the government does absolutely nothing to prevent the disease in future generations that still use water contaminated by pesticides used 20 years ago. On the other side the network of public hospitals and clinics are not equipped to treat and give a better quality of life to terminal stage patients.”

      Thanks for the comment, Hector. It sounds like you have experience with this disease. But since the change of government in El Salvador it is no longer true that the government does nothing. In cooperation with two nefrologists from Cuba, the Health ministry has established a national kidney health program coordinated by a Salvadoran nefrologist. They are doing sophisticated studies of the epidemic. In the Bajo Lempa there is now a Kidney Health Clinic that carries out an education program on kidney disease, how to reduce the risk. It also has the medicines needed and soon will provide peritoneal dialysis. This is a pilot program that can be implemented in any other affected zones that are found. The health minister has raised the problem wit the World Health Organization. They still have found the cause, but I am much more confident that they will.

      Another thing I wanted to mention is that the disease doesn’t come from the water. If this were the case then women and men would be equally affected becasue they drink the same water. But this isn’t the case. 4 men are affected for every 1 woman affected.

      Here is the Facebook page of the kidney program: http://www.facebook.com/nefrolempa

  2. December 12, 2011 7:50 am

    Is the fertilizer originating in the US? In the US “fertilizer” is generally processed waste from smelting, tire recycling, etc. with nitrogen added. This means it’s full of cadmium and other toxic components.

    • December 25, 2011 7:02 pm

      I don’t know the origin of the fertilizer used in ES, but heavy metal contamination is common in the agricultural chemicals used around the world. As I mention elsewhere in my blog, cadmium from fertilizer is one of the main theories advanced to explain the epidemic of kidney failure in Sri Lanka, which is very similar to the epidemic in Central America.

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