Meeting with Marvin Gonzales and Aurora Aragon, public health doctors at the medical university in Léon

Life is beautiful in Léon, and it’s always a pleasure to return there. It is there, at the relaxing, timeless Convento Hotel, that we met with Marvin Gonzales and Aurora Aragon, surrounded by the incredible sacred art collection assembled by the owners of the hotel, the Ortiz couple, two billionaires with a special taste for contemporary art from Central America.

Marvin and Aurora have been involved in research into the kidney disease since as early as 2002. They have had a front-row seat to CKDu since Western Nicaragua, with its huge sugar estates and mining industry, is by far the most affected region. Despite a clear lack of resources, they try, through their studies, mostly statistical ones, to establish common patterns and hunt down convergence among factors causing the disease.

Steering clear of controversies, their answers are characterised by scientific rigour with a subtle touch of diplomacy. Impossible to make them decide on the one cause of the disease due to a lack of valid scientific data.

© JP Lachougne

Rumporter: Marvin, how did you come to work on the kidney disease affecting cane workers in Nicaragua.

Marvin and Aurora: When the first studies were carried out, we were asked to analyse the results as experts. Our point of view is absolutely neutral, this is a matter of ethics. We are independent and completely focused on looking for the causes of the disease, whether on a social level (studying communities) or an occupational level (studying the various occupational groups involved). The social aspect is important because, apparently, there are social factors determining the prevalence of the disease: poverty, education level and job type, there’s a link between all of these.

R: What method do you use to carry out your research? What results can you share with the public?

M and A: We started with the archives. The first worrying figures we had access to date back to 1996 and reveal a sharp increase in cases, with more men being diagnosed than women. More than twenty enquiries have been conducted in Nicaragua ever since. In fact, we published the first paper in Central America.

From a practical point of view, our first study (Editor’s Note: in 2002) focused on five rural communities (Editor’s Note: five villages or neighbourhoods), each of which differed from the others in terms of their main activity and therefore their trades. To go into detail, we studied groups of approximately 60 people (men and women aged 20 to 60) in:

a community that cultivated cane and banana (altitude: 200 to 300m)
a community of miners and self-sufficient farmers (altitude: 200 to 300m)
a community of coffee growers (altitude: 800m)
a community of urban white collars (altitude: 200 to 300m)
a community of fishermen (at sea level)

(Editor’s Note: it is interesting to note that coffee must be grown at high altitude with less stifling temperatures)

The most affected communities were those consisting of miners and cane cutters, with a CKDu rate of 18%, whereas no cases were reported in the coffee group or the service group.

The lowest common denominator in the most affected communities were the stifling heat and the long working hours.

R: How did the Nicaraguan state reacted to these findings?

M and A: After this study, the Parliament declared the kidney disease an “occupational disease”, which changed a lot of things. A law was passed that stated that, if you met a number of criteria, you were recognised as suffering from an “occupational illness” and you were, in this respect, eligible for therapy (consultations and medication) paid for by the state social security and a monthly pension. All you had to do was to be diagnosed with kidney failure and prove that you had worked 150 weeks as a cane cutter.

But, in 2008, the law changed and became more restrictive, with a new condition requiring applicants to prove 26 consecutive weeks of work to benefit from the medical assistance programme. Cane cutters being mostly seasonal workers, this condition meant a huge decline in the number of beneficiaries.

R: More specifically, what has been put in place to fight against the disease? Are CKDu rates decreasing?

M and A: The state hasn’t done much, apart from the management of patients we mentioned earlier. Bear in mind that it’s only been since 2010 that heat stress and dehydration have become common topics. The number of cases has declined, although this can’t be attributed to real improvements in the situation. And there’s the counting method as well. Up until 2014, it was the University of Léon that was responsible for taking a census. We counted 754 cases that qualified for pensions. Those patients came mostly from Léon and Chinandega (Editor’s Note: to the north-east of Léon, halfway between Chichigalpa, where ISA is based, and Monterosa, the other large sugar plant). But, in 2015, the responsibility for counting cases was transferred to a private medical institution (a clinic) and figures decreased, with only 315 cases in 2015. There shouldn’t have been a decrease in these figures, I just think that the clinic doesn’t have the necessary skills and resources.

That being said, in terms of sugar estates, we have seen significant changes. First, sugarcane harvesting has become mechanised. Secondly, we have seen the implementation of programmes aimed at reducing working hours, the use of isotonic pockets for hydration and educational initiatives on hydration.

R: We have also seen these practices at Ingenio San Antonio. It looked convincing. Do you think the whole operation was staged, or was this a true reflection of the conditions all cane cutters employed by the Pellas Group work in on a daily basis?

M and A: We’ve never been able to enter the Ingenio ourselves and find out whether all of this is really put into practice. I know the doctor who works with ISA, and I don’t doubt his expertise and sincerity. My main criticism of them is that they refuse to communicate openly about what they do and the data they collect through their programmes. The main problem is a lack of transparency. For example, we would like to be better informed regarding the therapeutic research they’ve been conducting into stem cells. For example, we would like to know about the pesticides they use, so we can better cross-reference our data. It’s a shame that they’ve asked the Boston University and Houston University to carry out their studies and that they don’t accept to work with local protagonists (Editor’s Note: things have changed since this interview was conducted; read our interviews with Ariel Sacara and Jason Glaser)

R: How do you explain the fact that the controversy surrounds Ingenio San Antonio, although there are four large sugar producers in the region and the disease affects other workers in addition to cane cutters?

M and A: There are many circumstantial reasons, but I think the main one goes back to what I said earlier. Most cases have been reported in the Chinandega/Léon region, where ISA has established its operations, and I think poor communication is the main cause. The company is not responsible for global warming, but they must help us find solutions.


R: Nicaragua has been the focus of much attention but, supposing that the problem comes mainly from heat stress, dehydration and poor working conditions, it is reasonable to think that other sugar- and rum-producing countries have been impacted (Editor’s Note: for more on this, read the Science article on the disease becoming global). Do you have information on other countries?

M and A: Things are falling into place at a global level. In 2014, at a conference (WHICH???), we heard African kidney specialists mention an increase in the number of cases on their continent. An Indian doctor is currently completing a study of 69,000 cases, the findings of which will soon be published. In Sri Lanka, the disease has long been identified.

R: Coming back to rum, I am now going to list a number of countries and I would like you to tell me whether the disease is present there or not. Let’s start with Central America.

M and A: El Salvador: the situation is exactly the same as here in Nicaragua.
Costa Rica: idem
Mexico: a large study is being conducted there.
Peru: they are starting to look into the issue
Colombia/Venezuela: I don’t have any information on these countries
Jamaica: no cases have been reported
Dominican Republic / Haiti: no info

R: In conclusion, according to you, is it urgent to implement a simple solution such as the one Jason Glaser has been suggesting and offer workers rest, water and shade?

M and A: From a scientific point of view, what Jason suggests is very interesting because he wants to create an evaluation based on similar programmes in Salvador and at ISA (Editor’s Note: in June 2017 La Isla Network signed an exchange agreement with ISA for that purpose), so I support his effort.


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