In the blistering heat of Chichigalpa, the Sandinista heartland of north-west Nicaragua, weary men rest in shaded hammocks gazing at the endless rows of lofty sugar cane. The latest harvest weighs heavy on these communities that are being decimated by a deadly disease.

At least 20,000 people are estimated to have died of chronic kidney disease (CKD) in Central America in the past two decades – most of them sugar cane workers along the Pacific coast.

In the municipality of Chichigalpa, the disease is responsible for almost half of male deaths in the last 10 years. Sick men hasten their deaths by continuing to work in secret to support their families. The town is fast becoming a land of widows.

Walter, 32, will soon become another statistic; his wife another CKD widow. He has worked as a sugar cane cutter for 11 years. He is skinny, strong, affable and about to become a father. Walter knows he is dying, but hopes to see his child at least start school.

For his first nine harvests, or zafras, Walter was contracted to work for Ingenio San Antonio (ISA), Nicaragua’s oldest and biggest sugar mill. Each year, before the harvest, a company doctor would test his blood, urine and blood pressure before declaring him fit for the backbreaking work of cutting cane with a machete in oppressive heat.

Workers collect sugar cane at a plantation. Photograph: Osawldo Rivas/Reuters

But in 2012, his blood test showed the first signs of kidney dysfunction. His annual contract was not renewed and he was left without a medical follow-up, compensation or benefits.

“I was healthy when I started working for the company and sick when they got rid of me,” said Walter, who asked for his surname to be withheld to protect his relatives, 13 of whom work in sugar cane. “Every family here has lost someone, the work is making us sick, but there are no alternatives,” he said. “We are all dying from it, it’s a total epidemic.”

The exploitation of Nicaragua’s landless rural poor by a handful of wealthy families working with US agribusinesses was one cause of the 1979 uprising against the dictator Anastasio Somoza. The country is now ruled by a former Sandinista revolutionary, President Daniel Ortega, and he faces accusations of abandoning the country’s campesinos in pursuit of a political pact with big business.

In Nicaragua, they don’t come bigger than the Pellas Group, the conglomerate which owns ISA. Pellas companies also make the prizewinning dark rum Flor de Caña, and produce ethanol, a lucrative sugar cane byproduct used to make biofuels. The group’s CEO, Carlos Pellas – nicknamed the sugar king – is close to Ortega, and was recently declared the country’s first billionaire.

Sugar accounts from about 5% of Nicaragua’s GDP. Exports of sugar and its byproducts were £160m in 2013 – with more than a third sold to the US.



Critics say Ortega has ignored the plight of rural folk because he needs the sugar barons’ support to stay in power. Opposition MP Victor Tinoco, a former Sandinista politician expelled by Ortega in 2006, said: “We have a dramatic situation with people dying at a very fast rate from a disease clearly linked to harsh working conditions, yet they’ve been virtually abandoned by a president more interested in maintaining his business alliances.”

A woman holds a picture of her husband, who worked as a sugar cane cutter and died of chronic renal failure. Photograph: Oswaldo Rivas/Reuters

CKD was first documented in Costa Rica in the 1970s, and has since been detected throughout Central America. In Nicaragua, the second-poorest country in the Americas after Haiti, CKD is officially recognised as an illness that can be caused by work. To qualify for limited state disability benefits and specialist healthcare, patients must prove they became sick while working.

Walter and other cane cutters have not qualified for benefits. They say ISA does not give sick workers a copy of their medical records. An ISA spokesman said: “The company cannot compensate for something that it has not caused.”



The company points to food stipends and subsidised medicine it funds for sick ex-workers, and healthcare and education for current workers and families as part of its social corporate responsibility policies. “The company is responsible for the health and care for all its workers. It is a benchmark in Central America for its social responsibility policies,” it said.



But Dr Ben Caplin, a kidney specialist at University College London and part of a British team investigating CKD in Chichigalpa, told the Guardian: “The morally right thing to do is follow up patients with abnormal kidney function, if the company has the resources. There is no justification for not giving patients their test results, that is unethical.”

Outside the sugar plantations, there are very few jobs in Chichigalpa, so like many CKD sufferers Walter used a fake ID and went back to work cutting cane – this time in a “ghost team” for an ISA subcontractor. “Almost all 50 cutters in my team have the disease and are using false IDs. Of course the company knows, they see us working in the fields … the ghost teams are an open secret,” said Walter.

Several sugar cane cutters, speaking on condition of anonymity, said that some subcontractors recruit sick and underage workers to meet workforce demands. La Isla Foundation, a local human rights and public health group, said its researchers had found hundreds of sick workers employed by subcontractors on the current harvest, which started in November and will run until May.

ISA said the allegations were false: “There is no possibility that there is a sick person or a minor. We have a zero tolerance policy in this regard.”

There is a growing scientific view that CKD is linked to harsh work conditions, particularly long hours exposed to sun without sufficient shade, rest and water. Dr Catharina Wesseling, an epidemiologist based at the Karolinska Institute in Sweden said that while other factors - such as pesticides, heavy metals and genetics – could also play a part, there was “absolutely no doubt” that CKD was an occupational disease. “It predominantly affects male workers exposed to excessive heat and dehydration – conditions which are most severe in the sugar cane industry,” she said.

ISA does not accept there is a connection between CKD and working conditions on its plantations. “To date, scientific studies have not been able to determine the causes of CKD or establish a causal link between sugar cane work and the disease,” said a spokesman. ISA and other Nicaraguan sugar cane companies are supporting research into possible non-occupational causes – recently donating £430,000 for research into genetic and childhood links to CKD.

A worker fumigates a sugar cane plantation. Photograph: Oswaldo Rivas/Reuters

The company quotes a review of scientific literature on CKD carried out in 2010 by Boston University to claim there is “no evidence whatsoever that current labour practices or chemicals used by ISA now or in the past are generally accepted causes of CKD”.

The World Bank has also cited the BU research to defend its multimillion pound loans to the Nicaraguan sugar cane industry, including ISA. But Dr Daniel Brooks, who lead the BU study – which was funded by ISA – said these interpretations did not reflect their findings: “It would be incorrect to interpret the report as stating that working in sugarcane does not cause CKD.”

The Boston team’s subsequent field study found increased kidney injury and decreased kidney function among sugar cane workers, and concluded that heat stress related to strenuous work in high temperature likely played a role.

ISA says its field hands work on average six hours a day and rest for 20 minutes every hour under shade to minimise the risk of heat stress. Supervisors ensure everyone drinks 1.6 litres of water every hour, and in cases of heat stress or injury, a mobile health clinic is always on site.

But former and current ISA workers interviewed by the Guardian describe very different conditions. They say that during the harvest, cane cutters work for eight to 14 hours daily in temperatures often reaching 38C. They usually work a six or seven day week, cutting on average 7 tonnes of sugar cane every day.

People carry a mock coffin during a march to the capital, Managua, demanding that the government provide health assistance and answers over chronic kidney disease. Photograph: Oswaldo Rivas/Reuters

To put this in context, the US Occupational Safety and Health Administration advises that 15 minutes of heavy work in such conditions should be followed by 45 minutes of rest to avoid the body dangerously overheating. But ISA workers say they rarely rest as they are paid a piece rate of about 23 cordobas (55p) for a tonne of cane, and claim that supervisors pressure them to meet quotas. Palm trees offer limited shade and many complain that they are given water that smells of chemicals.

During the last harvest, company representatives took researchers from La Isla to a field where the work conditions appeared acceptable. However, on two unaccompanied visits, undercover researchers from the foundation said they found no evidence of shade, regular breaks, adequate water, mobile health clinics or protective clothing. Cutters told the Guardian that the company brings out the mobile clinics and shade tents only for government inspectors, the press and researchers.

Julio Rivas, who worked 22 harvests for ISA, has end-stage kidney disease. Photograph: Nina Lakhani

Julio Rivas, 53, who worked 22 harvests for ISA, has end-stage kidney disease which is crushing his strength but not his anger or sense of injustice. He said that he wanted an international boycott of Flor de Caña rum, which sells for £30 in the UK.

Rivas spends his £60 monthly pension on bus travel to a hospital 90 minutes away for dialysis three times a week. Apart from the exhausting journeys, he barely has the energy to leave his tiny brick and corrugated iron house. “When we get sick, the company washes its hands of us. People in other countries should know that,” he said.

In October, opposition MPs from the parliamentary labour committee tabled a motion to invoke a state of emergency in Chichigalpa so that CKD patients could get medicine, access to doctors and specialist services such as dialysis. The motion remains unheard by a parliament, which Ortega’s party controls.

In December, dozens of Chichigalpa’s sick cane cutters and widows marched 80 miles to the capital, Managua, to demand action. Villagers provided food and shelter in a show of support, as the protesters marched in baking temperatures. Among them was Juan Rivas, 74, Julio’s uncle and a former Sandinista fighter. He was diagnosed with CKD in 2001 after 30 years working in ISA’s fields. Three of his sons, all in their 20s, and one son-in-law also have the disease, yet somehow his fighting spirit remains intact.

“Whole families are being wiped out by this illness, we want to be compensated fairly, and make sure every sick worker has access to medical treatment, this is our right. We are disappointed with Commandante Ortega’s government, they have no concern for our health … us ordinary working people have been sold out,” said Juan Rivas. No one from the government met the marchers.



The girl holds a photograph of her grandfather who worked as a sugarcane cutter and died nine years ago of chronic renal failure. Photograph: Oswaldo Rivas /Reuters

• This article was amended on 18 February 2015 to correct the spelling of Dr Ben Caplin’s name.

