When doctors in rural Italy began to see a surge in cancer cases, they were baffled. Then they made the link with industrial waste being dumped by local crime syndicates. Ian Birrell learns about the tragic consequences.

A few days before I visited the rather scruffy Hospital of Saint Anna and Saint Sebastian in Caserta, a boy aged 11 arrived complaining of headaches. Doctors feared the worst – and sure enough, the case was rapidly diagnosed as another child with brain cancer. Some of these young patients arrive in agonizing pain, others mystified by falling over all the time; they do not know lethal tumors are swelling up inside their heads. Yet more turn up with cancer in their blood, their bones, their bladders. There are so many cases not all can be treated in the hospitals of Campania, a largely rural region of southern Italy.

It was too early to provide a prognosis for the boy with the brain cancer, let alone to offer real comfort to his distraught family. Yet in a town where doctors used to rarely come across a child with cancer, never mind brain cancer, they now see these traumatic cases crop up almost every month. Too many young patients are ending up dead, some barely out the womb but with bodies riddled with disease. Then there are all the women getting breast cancer unusually early, the men with lung cancer despite never smoking, the children born with Down's syndrome despite the comparatively young age of their mothers.

So why is this happening in an area north of Naples known as the 'Triangle of Death'? The answer, locals believe, can almost certainly be found in places such as an old quarry three miles away by the historic town of Maddaloni, which I visited with an energetic 57-year-old youth worker named Enzo Tosti. As we drove there, he told me he was having treatment to counter the high levels of dioxins found in his blood five months earlier. "My wife works for the hospital as a radiologist and she is very concerned," he said. "I thought about leaving for my health and going to live somewhere else, but where would I go? This is my land."

It was a glorious evening after a rain-sodden day, golden sun dipping through lavender-streaked skies as we turned off the main road and passed an orange grove, then fields full of fledgling bean plants. It was easy to understand his attachment to this striking area of Italy, some of the most fertile land in Europe thanks to the volcanic eruptions of Vesuvius to the south. But for all the natural beauty, the scenes confronting me could not have been more depressing.

As we clambered from the car, Tosti clamped his hand over his mouth and told me to hurry. Rubbish lay everywhere, with plastic sacks, paint containers and glass bottles littering the ground. I stumbled over the undulating land, pockmarked with crevices and potholes, as I struggled to keep up with my guide. Descending one dip we were struck by the acrid stench of chemicals and saw a small plume of smoke seeping from the earth. But Tosti waved away questions. "We can talk in the car," he said. "Let's get away from here."

'I thought about leaving for my health and going to live somewhere else, but where would I go? This is my land.'

As we drove away, he explained how the mafia had dumped huge quantities of contaminated industrial waste there, and had then unexpectedly obtained backdated permission for their actions. Yet these hazardous materials were left in the midst of prime agricultural land, next to a car dealership, with bingo halls and furniture stores down the road, and just a few hundred yards from a town of 39,000 people. A criminal investigation was launched 18 months ago into the incident, but local people do not expect to see convictions as a result of it.

For this was far from an isolated incident. There are thousands of similar dumps all over this once-paradisiacal slice of Italy: in canals and caves, in quarries and wells, under fields and hills, beneath roads and properties. According to one mafia supergrass, for many years businesses in the prosperous north of the country paid organized crime to dispose of toxic waste illegally rather than pay far higher rates to have it dealt with safely. So the Camorra, the crime syndicate that operates across Campania, contaminated great chunks of their own backyard, littering the landscape with heavy metals, solvents and chlorinated compounds. There is evidence that barrels were buried, containers driven into rivers, hazardous materials mixed in with household rubbish, chemical sludge spread on fields as 'fertilizer', asbestos burned in open air. And only now is the tragic legacy of the mafia's idiocy finally becoming clear.

But it is too easy to blame just gangsters for the probable deaths of thousands of people. The story of this illegal waste disposition stains Italy. It reveals the dark side of capitalism; there are allegations of state complicity, of cover-ups by police, politicians and prosecutors. One mafia kingpin even claimed trucks drove from Germany carrying nuclear waste to dumps in Campania. Yet even if such things have been halted now, this region also offers wider lessons for the world as the rich West ignores similar activities in low-income countries. Doctors and scientists believe this polluted Italian landscape provides a perfect experiment in 'exposomics' – the evolving study of health damage caused by exposure to harmful chemicals in environmental contamination.

The saga's roots can be traced back to a devastating Italian earthquake in November 1980 that left almost 3,000 people dead and 280,000 homeless. Billions of pounds in aid poured in, although most ended up in the wrong pockets. Rebuilding the ruined roads and buildings boosted mafia profits, since they dominated construction in the region – a handy way to launder money from drugs and prostitution. As cash flowed in, the clans expanded their interests in areas such as quarrying, which provided raw materials for their work. Then an enterprising businessman-lawyer with gangland links who owned several waste dumps realized they could make big money by hiding industrial waste amid the detritus of daily household lives. So in the late 1980s, the mafia moved into a lucrative new area of business.

Soon farmers began to notice strange incidents in fields and forests. They had been given a new liquid fertilizer, yet it seemed so strong that it corroded metal tanks, leaked from lorries and stunted plants. One day a forestry official in Brescia gave a young journalist named Enrico Fontana a vial of this fertilizer and said "smell what they are giving people to spread on agricultural land". The reporter recoiled at the bitter stench: it was cyanide. So in 1990 he published two exposés in L'Espresso, a prominent news weekly, disclosing that organized crime was dumping dangerous materials on fields and in landfill sites.

Evidence to support his claims slowly began to mount. A mafia supergrass called Nunzio Perrella told investigators in Naples all about the new trade, leading to scores of arrests of gangsters and corrupt officials in March 1993. They were soon free, however. Yet the following year Fontana – now working on investigations for Legambiente, an environmental group – published a report called Garbage Inc., revealing the same people were trafficking illegal waste in other parts of Italy. There was a public outcry, a parliamentary commission and polluted parts of Campania were declared an officially degraded zone.

"We thought we had a result. Our job was done," Fontana told me with a rueful smile as we sat drinking coffee in the sun outside Legambiente's headquarters in Rome. "But then nothing happened. Nothing. What was missing was that we did not put together legal dumping with illegal dumping. And while it was obvious this was bad for the land, we did not notice any health outcomes at that stage, since they are not obvious immediately."

Fontana coined the phrase 'eco-mafia' and began issuing annual reports into their actions. Yet he was unaware at the time of two other important developments. First, a police officer in Campania named Roberto Mancini stumbled on the scale of the mafia's new activities, discovering they were hiding toxic waste from businesses in the industrial north among local household waste poured into landfill sites. He wrote a memo for his superiors detailing his findings. But the report was buried and Mancini was later transferred to Rome. With cruel irony, Mancini died two years ago from cancer, his career wrecked by attempts to unwittingly save thousands more from the same fate.

Then came the case of Carmine Schiavone, one of the most important supergrasses in Italian history. As a leader of the notorious Casalesi clan in Naples, he confessed to losing count of the number of people killed on his orders. His explosive testimonies revealed widespread bribery of politicians and eventually put 16 crime bosses behind bars for life, after trials that dragged on for years and left five witnesses dead. Yet Schiavone claimed to have broken the mafia code of silence out of fears for the environment. And his most devastating disclosures were given in private to a 1997 parliamentary committee in Rome about toxic waste dumping – and then astonishingly kept secret for almost 17 years.

"We are talking about millions of tonnes," said Schiavone, who even claimed German nuclear waste was ferried to Campania. "I knew that people were doomed to die." In front of the committee he described dumping operations taking place in the dead of night, guarded by men in military uniforms and with the connivance of senior police officers, politicians and businesspeople. The supergrass showed state officials the locations of sites because, he predicted with startling accuracy, nearby residents would be "dying of cancer within 20 years".

[Former mafia leader Carmine] Schiavone claimed to have broken the mafia code of silence out of fears for the environment.

This illegal trade was a by-product of tax dodging in a country with one of the highest levels of evasion in western Europe. Businesses massaging their incomes had to mask the scale of their activities – and that meant hiding huge amounts of hazardous waste. By the turn of the century, so much was being dumped in Campania it could not be hidden easily among household rubbish, so the mafia began burning it. Trucks would turn up at night, waste would be emptied, then huge fires started – 6,300 times a year at one point. Locals lined doors with damp towels to keep out vile smells – and the area was branded the 'Land of Fires'.

The fires intensified environmental damage and spread the health consequences. Soon doctors began to notice an upturn in birth defects and cancers, which they would discuss in bafflement over meal breaks. Among them was Alfredo Mazza, a lively Neapolitan – then training to become a cardiologist – who enjoys the cut and thrust of political campaigning. "Lots of people were becoming ill," he said. "I knew young people who were sick from school, some friends died, lots of people in this area were dying. People said to me: you are a doctor from this area – you must take on this battle."

Mazza asked health authorities for the cancer data for an eastern region of Campania with high levels of dumping – and when he received the results, he believed it showed evidence of links between environmental degradation and a rising incidence of tumors. Male death rates from bladder and liver cancer in this rural district were about twice national rates, for instance, and female mortality from liver cancer was more than three times the Italian average. And while improved diagnosis and treatment were boosting survival rates elsewhere, local medics were seeing rising mortality and younger patients. "The age was important," he said. "Cancer is usually found in older people, but these were younger people dying."

The pugnacious young doctor took the devastating data to a local prosecutor and demanded action, but was fobbed off. So he wrote to the Lancet, which published his landmark work in September 2004 in what was to be the first of many reports into the Land of Fires. The article provoked a furore, fueling local protests over a planned new incinerator, yet led to little real action from the authorities – although Mazza told me he learned later from a friend that Italian intelligence began monitoring him as a 'troublemaker'.

Now an established heart consultant who has published subsequent studies into the health consequences of hazardous waste, Mazza admits it is impossible to prove precise links between toxic materials, tumors and congenital malformations. But he believes they are only just beginning to see the full scale of health problems. "We are living in the Triangle of Death. These areas suffered terrible damage for many years. Yet still we do not know how many areas are affected, how bad the damage will be or how long it will last."

Two years after his Lancet report, the tales of gangsters driving across Italy to dump lorries filled with toxic waste in rivers and bury contaminated containers under lush fields reached a wider audience when highlighted in Gomorrah, the ground-breaking mafia exposé by journalist Roberto Saviano. Among the 6 million buyers of the book was an oncologist in Naples named Antonio Marfella, long baffled by both his increasing number of patients and their decreasing age. He knew this was a global phenomenon, yet the speed of change seemed alarmingly fast in Campania.

Marfella held a senior post as head consultant at the Fondazione G Pascale in Napoli, a 235-bed hospital that is the region's only cancer centre. He said they started seeing the surge in cases around the turn of the century, with the average patient age plummeting from 60 years old to under 40. Suddenly once-rare bone cancer cases became commonplace in children, and the age of most breast cancer patients fell below 40, which is when screening starts in Italy. "Although we are a city on the sea and not industrial, it was like we were living in one of the world's worst industrialized areas," he said.

Naples had long been infamous for inept management of its rubbish, with landfill sites filling up strangely fast. Indeed, even as Marfella turned the book's pages in 2007 there were protests in the streets from residents fed up with the stench of rubbish rotting in the summer heat. Suddenly the white-haired consultant began to understand what was going on around him: "It opened up a vision that seemed unbelievable," he said. "We knew there was mismanagement of household waste, but we did not know that organized crime had gone outside its usual activities of drug dealing and prostitution into hazardous waste."

In the nearby town of Acerra, dead and deformed sheep had begun appearing. Then the 50-year-old shepherd tending this flock turned up at the hospital with such aggressive cancer riddling his bones and his blood that doctors could not determine where it had started; one month later he was dead. His daughter asked for tests on his body and these revealed unusually high levels of dioxins. After it emerged his sheep had been tested four times with similarly disturbing results, she launched a court case for damages.

Marfella gave expert evidence in court, which led to a request to speak about the situation in the Italian parliament in January 2008. "I said there were the same levels of toxins in these agricultural areas as were found in industrial sites, which was a paradox. I said it was like postindustrial sites – and I suggested a hypothesis I believed from Gomorrah." Yet he was demoted on his return from Rome for being 'alarmist', a decision that has cost him thousands of pounds a year in lost income.

Around this time a woman named Anna Magri gave birth to Riccardo, her second son. When I met the 39-year-old car retailer in her neat flat in a village near Caserta, the boy's tiny shoes were displayed alongside his picture on a dresser: he died shortly before his second birthday, having spent most of his short life fighting leukemia discovered when he was six months old. "We thought he was teething which was why he was so upset, crying all the time. I was breastfeeding him but I could not pick him up because he would scream. He was in so much pain," said his mother.

Anna, who was pregnant during the 2007 rubbish crisis, remembers thick black smoke rising over her village from waste set alight on a nearby hill. "We did not think about the toxic waste issue because it had not come out yet," she said. "I had seen fires all over the place, but now I know what they were. I am convinced his death was due to the toxic waste when it was burning, with all the illegal dumping."

It will never be established whether her son was dealt a raw deal by fate or if his death was more sinister. One study, however, indicated significantly higher levels of dioxins in breast milk from mothers in the worst-afflicted area than from others living in surrounding areas. Other research has found worrying concentrations of dioxins and polychlorinated biphenyls (PCBs) in animal milk, even in the buffalos that produce the region's famous mozzarella cheese. PCBs are man-made compounds once used widely in electrical products and are banned in many countries due to environmental and health concerns.

I asked Anna what she thought about the goons she believes killed her child, people she passed daily in the street. "They were stupid because they live here and their children live here too." Yet this shocking saga goes far beyond the stupidity of greedy gangsters. The Italian state is guilty of at best grotesque and fatal incompetence, at worst a murderous cover-up in league with wealthy, tax-dodging industrialists that may have caused the deaths of at least 2,000 people already, according to one recent official study.

In 2004 there were more than twice as many known dumping sites in Campania than in the northern region of Lombardy; four years later, this number had more than doubled. The fires burned, but officials ignored them. One pediatrician showed me a map of these microdumps, each one a black dot, heavily clustered in the Triangle of Death zone around Acerra, Nola and Marigliano. Then he showed me another he had made with red dots denoting cases of child brain cancer overlaid on top; almost all overlapped in the same small area of the region.

This shocking saga goes far beyond the stupidity of greedy gangsters. The Italian state is guilty of at best grotesque and fatal incompetence, at worst a murderous cover-up.

Yet only now is the full extent of the scandal coming to light. Partly this is thanks to a campaigning local priest named Father Maurizio Patriciello, a former nurse who writes for the Italian bishops' newspaper and enjoys stirring things up on social media. One hot night in June 2012 he could not sleep because of the smoke and stench of burning chemical waste, so he went on Facebook at three in the morning and asked if others were suffering the same effects. By six he had more than 1,000 responses from neighboring villages, so he went to his bishop and demanded action.

"Families here are terrified," the silver-haired, smooth-talking Catholic priest told me when we met in his church on a grim estate, watched intently by a gang of hooded men outside the heavy iron gates. "They know that even today there are so many sick people. They have to go for treatment in the north because hospitals here are full. If a woman asks for a mammogram they give it to her in three months, but if you wait that long it can be too late."

Patriciello helped grieving parents such as Anna form protest groups, lobbied politicians in Rome, penned polemical articles, organized huge marches and joined with campaigners who sent pictures of mothers with their dead children to the Pope and Italian president. He even met Schiavone before the supergrass died two years ago, finding "an insignificant old man with white hair." Patriciello claims that the gangster confessed his crimes to the priest, but claimed the worst offenders were the industrialists dealing with the mafia, since they knew the devastating damage of their deeds. It is hard to disagree.

It also emerged two years ago that the United States Navy, whose European command is based in Naples, had conducted its own three-year, $30 million study into the local air, soil and water. It tested hundreds of contaminated or alarming locations, finding high levels of 'unacceptable health risk' in private wells and worrying levels of uranium in 5 per cent of samples. It found there to be no impact on military personnel, but three areas near its base were placed off-limits, tap water was banned and troops were advised to avoid ground-floor flats, where the risk of inhaling contaminants was highest.

Thanks to the campaigners and hefty European Union fines for failing to combat illegal waste disposal, Italy's politicians were finally prodded into action. Farming was banned around some contaminated sites. Then they passed a special Land of Fires act of parliament in 2014, which banned the burning of waste while putting extra cash into cancer detection and public health promotion in the region. Parliament also ordered the National Institute of Health to collect all available epidemiological evidence. An earlier study by the body had found a correlation between hazardous waste and health outcomes such as cancer mortality and birth malformations, but no direct cause.

The results of the inquiry, which looked into mortality, cancer incidence and hospital admissions in 55 municipalities, emerged earlier this year – and were devastating. Life expectancy in Campania two years lower than in the rest of the nation. Mortality rates in the Triangle of Death 10 per cent higher for men than elsewhere in the region, 13 per cent higher for women. More cancer cases in these bucolic rural areas than in the most contaminated industrial sites. These included a 17 per cent rise in cancers of the central nervous system for children under 14 around Naples – and a 51 per cent rise for infants in their first year, who are particularly vulnerable to environmental contamination because of their physiology.

"It is not that every case is down to the toxic waste, but you can see a clear pattern," said Pietro Comba, one of the authors of a report that directly blamed illegal dump sites and uncontrolled burning of waste. "There were particular signs with stomach, liver and lung cancer, plus breast cancer in women. And it was significant that these excesses are not uniform across the region. In many municipalities there is no departure from the norm, then it is very high in some others."

Even these staggering findings offer only correlation, not proof of cause. But they add to a growing body of global evidence linking pollution to health problems: there's incontrovertible evidence of ocular and central nervous system damage having been caused by the dumping of deadly toxic waste in Abidjan, Côte d'Ivoire, in 2006, just as there are studies into contaminated waste dumps in Asian countries and the USA indicating impaired cognitive development. As Comba says, it is far harder to determine what causes a tumor to develop in a child's brain than to find a link between asbestos and mesothelioma. "We have very strong evidence, but we cannot say with total certainty that this toxic waste is leading to child cancer."

Slowly but surely, Italy is moving to clean up these dumps and clear up a tragic scandal, although as yet there have been few prosecutions, and campaigners remain pessimistic key perpetrators will ever meet justice. "These people will never come to court because they are important industrialists," said Marzia Caccioppoli, 40, a seamstress whose only child died three years ago of a type of brain cancer usually seen as the result of radiation exposure in adults. "They have poisoned our land and stolen our children."

But while industrialists no longer pay gangsters to bury hazardous chemicals beneath grazing buffalo in Campania, rich northern nations and multinational companies are still dumping chemical, electrical and industrial waste in low-income countries. This has been dubbed 'toxic colonialism'; spot checks have found one in three containers leaving the European Union contain illegal e-waste, for example. Yet given the growing body of evidence, not to say sheer common sense, companies concerned must be aware of the consequences for the children picking apart wiring and their parents sifting through waste in places such as the Philippines, Nigeria and Ghana.

When I visited the Hospital of Saint Anna and Saint Sebastian in Caserta, where the latest case of a child with a brain tumor had been diagnosed, I met a passionate pediatrician named Gaetano Rivezzi. Born in a village seven miles away, he was the man who showed me the disturbing maps overlaying child cancer cases on dump sites. "Before it was paradise here – there were 1,000 things you could grow. Then priests started to count the funerals of children and doctors became more concerned," he recalled.

Rivezzi told me he had been in medicine for three decades. "Campania is a laboratory to understand the link between the environment and health. The danger can't be undone, but it is important and we must learn from this," he said. "When I began, a child with cancer was incredibly rare. Not now, not here. The tumors are different, the diseases are different, the pathology is different. And you can see the same things now in Africa, where pollution is leading to serious problems."

He is right to say we must learn from a scandal that has left death and devastation in its wake across such a beautiful part of Europe. It scars the state of Italy, not just the fields, hills and waters of Campania. Yet perhaps the ultimate tragedy is that gangsters in all their different guises seem indifferent to the consequences of such actions, and still carry on their deadly game of dumping toxic waste around the world.

This article first appeared on Mosaic and is republished here under a Creative Commons license.​