Deadly Illness in Central America Baffles Experts

It was in the off-season, out on the baseball field, that some residents noticed a change. Base-stealers were l...

It was in the off-season, out on the baseball field, that some residents noticed a change. Base-stealers were lethargic. Pitchers were losing their aim. In the evening, outfielders were burning up as if standing under the scorching sun of the day.

_That_s Mosquito, now dead,_ said Arnulfo T__llez Aguilera, 49, pointing to a photograph of his smiling teammates before their muscles withered, like his. _That_s my brother, Danilo, dead too._

Across Central America, a painful disease that affects the kidneys has killed at least 20,000 people over the past decade and has become the leading cause of deaths in hospitals among men in El Salvador. But the illness, often called chronic kidney disease of unknown causes, or CKDu, is so poorly understood that it still does not have a universally agreed-upon name.

Theories vary drastically, citing a combination of possible factors, including heat stress, chronic dehydration, toxic chemicals, painkillers, sugar consumption and even volcanic ash.

But there is a rare point of consensus, many researchers say: Nicaragua_s sugar cane heartland _ in particular Chichigalpa, the town that is home to the country_s largest sugar mill _ has been one of the hardest hit places in the world. Cane-cutting fathers and sons in the same family have died, and seemingly healthy young men are quickly wasting away.

The Nicaraguan government, the country_s sugar mills, even the World Bank, which has poured tens of millions of dollars into the sugar industry here, all say that until the mystery of the disease is solved, there is little they can do to prevent it. Now, after years of inconclusive research, the Centers for Disease Control and Prevention is stepping in to help with some of the most ambitious studies of the illness yet.

But the sick former sugar cane workers here have little faith that more studies will bring improvements anytime soon. The fact that the research will be funded entirely by the sugar industry is only fueling the distrust.

_I don_t think anybody has clean hands,_ said Kristen Genovese, a lawyer who helped sick former workers file a complaint against the World Bank_s lending arm in 2008 for lending $55 million to the sugar mill here, called San Antonio, without looking into the disease or the possibility that it might be connected to the industry.

_The government of Nicaragua has done nothing to help these people,_ said Ms. Genovese, who was with the Center for International Environmental Law in Washington when she filed the complaint. And the World Bank, she argued, _should have spotted this problem, and didn_t do anything about it, and continued to invest in sugar in the region._

Along the Island of the Widows, as one area next to the big sugar mill is called, the disease is such a dominant part of life that health updates sometimes replace _hello._

Before each harvest, workers must take blood or urine tests that measure kidney function to determine whether they will be allowed to return to the fields. In preparation, some ingest concoctions of fresh tamarind juice and linseed oil, avoid the sun and force themselves to rest. Others simply pray.

_When you_re sick they tell you, _You_re done here,_ _ said Mr. Aguilera, who failed the test in 2001. _They washed us away, without any kind of helping hand._

The complete dependence on the industry, whatever the risks may be, is stark. Glassy-eyed men are convinced that something in the water or the fields made them sick. Yet they are desperate to return to work, borrowing their wives_ and sisters_ identity numbers in a furtive attempt to stay employed. In one neighborhood, even conservative studies show that one in three men have the illness.

_The sugar mill said that all of this is part of nature. But this isn_t nature,_ said Gilma Urbina, 37, a mother of five who recently lost her husband to the disease.

_The day that my husband died, he died at 6 in the morning,_ Ms. Urbina said. _Down the block, another one died at 2. The next day, three more died._ She added, _I think we_re going to end up without any people here._

Radically different perceptions of the cause have stirred debate over who should cover the enormous costs of treating patients with the disease.

Mario Amador, general manager of Nicaragua_s National Committee of Sugar Producers, one of the groups financing the C.D.C. studies, said the sugar cane business in Nicaragua had quadrupled over the past 10 years into a $500-million-a-year industry, supplying everything from Coca-Cola to rum makers. But he said the annual kidney exams, which he called necessary to avoid putting sick workers at additional risk, had created the false impression that the mills were linked to the disease.

_I don_t think there_s any relationship between CKD and the sugar cane industry,_ Mr. Amador said.

Executives at the San Antonio mill in Chichigalpa say they also take the annual test, but it is rare that they fail.

_We drink the water here, too,_ said _lvaro Berm__dez Castillo, the mill_s administrative director, who has been working at the mill since the 1970s.

Lawmakers in El Salvador and Sri Lanka, where similar kidney problems have emerged, have moved to ban certain herbicides. But few of the researchers who are focusing on Nicaragua _ the country with the highest death rate from the disease, according to the Pan American Health Organization _ are willing to say the answer is that simple.

Agricultural chemicals alone, they say, do not explain why the disease has been detected in some Nicaraguan miners at similar rates, why women who grew up on the sugar mill_s grounds have generally been unscathed, or why workers here are affected at much higher rates than people exposed to the same chemicals elsewhere. Perhaps extreme heat, dehydration, the intensity of the labor or other factors play a role, the researchers say.

_The problem is, this is a silent killer,_ said Aurora Arag__n, a Nicaraguan researcher.

Residents say they began noticing the sickness shortly after the Nicaraguan government, which had nationalized the sugar industry, returned the mills to private owners in 1992. As the operations at San Antonio rapidly expanded, driven partly by American and European appetites for sugar and a move into ethanol production, families say the cane cutters _ many of whom had been born in a hospital on the mill grounds and went to a school there _ grew sick in larger numbers.

The mill says it pays the government every year so that workers can receive pensions and health insurance. Without a scientifically decisive link to the disease, industry officials question why they should be responsible for more.

Throughout the early 2000s, lawsuits seeking compensation from the mill mostly went nowhere. Then in 2008, a workers_ group known as the Association of Chichigalpinos for Life filed the complaint against the World Bank_s lending arm, known as the International Finance Corporation, which had lent the mill $55 million. The complaint alleged that by failing to acknowledge the disease in documentation about the project, it had violated its own lending standards.

When deciding whether to invest in the industry, no one had brought up or looked into the disease, a spokesman for the finance corporation said.

_CKD is not a common disease in the sugar sector worldwide, so I.F.C. did not look into this issue at appraisal,_ said the spokesman, Aaron Rosenberg, based in Washington. The institution has lent more than $100 million to Nicaraguan sugar mills over the past decade.

After the complaint, the mill agreed to provide food and other assistance to widows and sick workers. It also agreed to open its door to a team of outside researchers.

Yet _nature can be very reluctant to give up its secrets,_ said Daniel Brooks, a researcher from Boston University, which was selected to investigate the disease by a committee that included mill executives and sick workers.

Five years later, Dr. Brooks has as many questions about the disease as answers. His report published in 2012 neither entirely ruled out nor formally endorsed any theory.

Now, Dr. Brooks and his team from Boston University will be leading the charge in three C.D.C. Foundation studies, which he believes could have implications far beyond Nicaragua.

_We don_t know if this is the tip of the iceberg yet,_ he said. _If this is heat stress and the climate is changing in the direction of getting hotter over time, are we seeing something that will happen much more in the future and maybe extend its geographic range?_

_Similarly, if it_s agrochemicals, the agrochemicals they use are very widespread across the whole world,_ he added.

For now his team is more focused on two other areas: whether the disease has a genetic component and its presence in children. Research into work-related risk factors is also planned, but sugar industry funding so far covers only preliminary work. The C.D.C. says that numerous measures are in place to protect the research from undue influence. Some others are suspicious.

_If your main concern is limiting liability, you are never going to get to the bottom of what is causing this,_ said Jason Glaser, president of La Isla Foundation, an organization focused on the disease in Nicaragua.

On a recent afternoon, Mr. Aguilera was feeling well enough to take careful steps toward the graves of his two brothers and father, all victims of the disease. He was thrown off by all the new mounds of earth that had appeared _ at least 30 over the past few months.

_I will be buried over there,_ he said calmly, pointing to a plot nearby.

He died three weeks later.

New York Times | By HEATHER MURPHY

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