Chronic Kidney Disease in Nicaraguan Sugarcane Workers: A Historical, Medical, Environmental Analysis and Ethical Analysis

摘要

Over the past two decades, roughly 20,000 people in Central America have died from chronic kidney disease of unknown origins (CKDu).[1] CKDu is growing into an unsolvable epidemic due to the mysterious cause of the disease and the little treatment available in the underdeveloped region. CKDu primarily affects sugarcane workers in Nicaragua and El Salvador, but it has also appeared in the rice paddy fields of Sri Lanka. Researchers from Sri Lanka, Boston University, and University of Colorado have proposed causes for the disease such as the pesticide glyphosate, occupational hazards like heat and dehydration, and sugar consumption, respectively; however disagreements still persist. The goal of this paper is to add to the claims already made so that a clearer hypothesis is formed. The paper will also focus on CKDu in Nicaragua to raise more awareness and to pressure the sugarcane companies into changing the country’s policy. Many aspects of CKDu will be analyzed including a history of sugarcane and pesticide usage, medical information about CKDu and Nicaragua’s treatment of the disease, ethics of the companies, and the environmental impact. The methods used in this research include observations and discussions with former sugarcane workers and their relatives during a two week trip to Nicaragua. Introduction Chronic Kidney Disease of unknown origins (CKDu) has been the cause of death for roughly 20,000 people in only two decades. Although a typically treatable disease, certain factors contribute to the increasing CKDu death toll; factors include conflicting multiple causes, treatment availability, and sugarcane and government policies.At present, three main theories propose a cause for CKDu presence in Central America, and this paper will propose a fourth one. First, the Ministry of Health in Sri Lanka and El Salvador both argue that the agrochemicals such as glyphosate cause CKDu. Dr. Carlos Orantes, a kidney specialist with El Salvador’s Ministry of Health, names three factors in the development of CKDu: the use of prohibited pesticides, combinations of pesticides, and no protection from pesticides.[2] Second, a Boston University research team contends that “occupational” hazards like dehydration from the extreme heat cause CKDu.[3] The team is also conducting research in genetics and early kidney injury in adolescents as other reasons for the cause.[4] Their research was controversially funded in part by the sugarcane industry through the CDC Foundation; but they deny any conflict of interest.[5] Third, University of Colorado researcher Richard Johnson, found that large amounts of sugar causes tubular damage similar to those in CKDu patients. He argues that the worker’s excessive consumption of sugar is the cause.[6] Each theory has experienced various success in being accepted by the sugarcane companies, but none have been accepted as the outright reason for CKDu. The fourth theory, presented by researchers at Saint Joseph’s University in Philadelphia, will argue that CKDu is caused by a combination of these theories. Our theory is that extreme heat and dehydration combined with toxic agrichemicals weaken the kidneys and leads to CKDu. The reasoning behind this theory will be analyzed in a historical, medical, environmental, and ethical section.In addition to conflicting theories, treatment availability in Nicaragua adds to the increasing CKDu death toll. Treatment for chronic kidney disease would typically include dialysis or kidney transplant; however Nicaragua is the second poorest country in the western hemisphere so resources are limited. In 2009, one article reported that less than 10 living donor kidney transplantations were attempted, while in recent years no dead donor kidney transplantations were initiated.[7] Even if the number of transplants were increased, the cost would still be too much for a sugarcane worker, whose monthly income is at most 6,642 (USD 259.6) Cordobas.[8] The estimated cost for kidney transpla