Dissertation English

TO WHAT POINT HAS THE SANDINISTA GOVERNMENT PERPETUATED THE PREVALENCE OF
CHRONIC KIDNEY DISEASE OF UNKNOWN AETIOLOGY (CKDu) IN THE SUGARCANE
PLANTATIONS IN CHICHIGALPA, NICARAGUA?
A dissertation
presented for the degree of
B.A. (Honours)
in the University of Strathclyde
January 2014
by
SARA WARDEN

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Contents Page
1. Introduction
2. Chronic Kidney Disease of Unknown Aetiology (CKDu)
3. Role of Sugarcane Plantation
i. Working Conditions
ii. Food stipends
iii. Violation of freedom of association laws
iv. Environmental Factors
v. Union affiliations
4. Role of the International Market
i. US and EU Imports
ii. Work Bank
iii. Biofuels
5. Role of the Nicaraguan Government
i. Lack of Access to Healthcare
ii. Riots and Police Brutality
iii. Opposition to La Isla Foundation
iv. Lack of Involvement in Dialogue
v. Social Security Issues
vi. Nicaraguan Business Interests
6. Conclusion

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1. Introduction
Nicaragua is the largest country in Central America with a population of over 6 million[1
.
The Government is a unitary presidential constitutional republic][2
and, since 2006, the
President has been Daniel Ortega of the left-wing Frente Sandinista de Liberacion
Nacional (FSLN)][3
. Nicaragua has had a turbulent political history, with several military
dictatorships - the most prominent of which was the Somoza Dynasty which ruled the
country for 43 years between 1927 and 1979][4
.
Currently with a GDP of $10.51 billion according to the World Bank][5
, Nicaragua is the
second-poorest country in the Western Hemisphere, and has an economy which
depends largely on foreign aid and exports of commodities such as coffee and sugar][6][
.
The sugar industry in Nicaragua employs an estimated 35,000 workers][7
. The biggest
1 'Población Total, estimada al 30 de Junio del año 2012', en el Instituto Nacional de Información de Desarrollo de Nicaragua
<http://www.inide.gob.ni/estadisticas/Cifras%20municipales%20a%C3%B1o%202012%20INIDE.pdf> [accessed 02 October
2013].
2 Peddicord, K. (2013) How to Buy Real Estate Overseas. John Wiley & Sons: New Jersey, pp 227.
3 Staten, C. L. (2010) The History of Nicaragua. ABC-CLIO: California, pp 150-51.
4 Hamilton, L.H. and Inouye, D.K. (1995) Report of the Congressional Committees Investigating the Iran/Contra Affair. DIANE
publishing, Pennsylvania, pp 25.
5 'Nicaragua', cifras de la Organización Mundial de la Salud <http://data.worldbank.org/country/nicaragua> [accessed 01
November 2013].
6 Hess, M. L. (2008) Doorways to Development: Foreign Direct Investment Policies in Developing Countries. ProQuest:
Cambridge, pp 256-59.
][ 'Labour Conditions in the Nicaraguan Sugar Industry' por Profesionales Para la Auditoria Social Empresarial (PASE) y el Fondo
Internacional de Derechos Laborales (ILRF) <http://www.laborrights.org/sites/default/files/publications-and-
resources/nicaragua_sugar.pdf> [accessed 01 November 2013] pp 5.
7 'Labour Conditions in the Nicaraguan Sugar Industry', pp 6.

2 0 0 9 0 0 5 1 8 - P a g e | 4
producer of sugar in Nicaragua is Nicaragua Sugar Estates Limited (NSEL), which
cultivates around 24,000 hectares of sugarcane in the departments of Chinandega and
León][8
.
Within Chinandega, in fact, is the largest sugar refinery in Nicaragua - the Ingenio San
Antonio Mill (ISA). ISA provides around 43% of the country's sugar][9
and also produces
molasses for Flor de Cana, a premium liquor company which is owned by the same
conglomerate as NSEL - the Grupo Pellas][10
. Grupo Pellas owns 25 companies in
different sectors such as financial, agroenergy, tourism, technology, automotive
marketing, health, telecommunications, entertainment, real estate and insurance][11
.
Carlos Pellas Chamorro, the Chairman and major shareholder of Grupo Pellas is the
richest man in Nicaragua, with an estimated net worth of $7.5 billion, a staggering 70%
of the total GDP of the country][12
.
Nicaragua is currently producing and exporting ethanol based on sugar cane. In 2011/12
alone, the Pellas family exported to the US 10 million litres of ethanol produced at its
San Antonio refinery][13
. The Grupo Pellas is deeply involved with COSEP (Consejo
8 Whisnant, D. E. (1995) Rascally Signs in Sacred Places: The Politics of Culture in Nicaragua: The Politics of Culture in
Nicaragua. University of North Carolina Press: North Carolina, pp 118.
9 'Datos Finales de Producción: Zafra 2012/13', del Comite Nacional de Productores de Azucar
<http://www.cnpa.com.ni/index.php/category-blog> [accessed 01 November 2013].
10 'Nuestra Tradición', en Flor de Caña <http://flordecana.com/es/heritage/> [accessed 01 November 2013].
11 'Empresas Afiliadas', en Grupo Pellas <http://www.grupopellas.com/empresas.htm> [accessed 01 November 2013].
12 Bogan, J. 'Navigating Nicaragua' en Forbes (20 October 2009) <http://www.forbes.com/2009/10/20/grupo-pellas-nicaragua-
business-chamorro.html> [accessed 01 November 2013].
13 'Nicaragua Sugar Annual Report 2013', por el Red de Información Agrícola Gobal (GAIN) <http://gain.fas.usda.gov/Recent
%20GAIN%20Publications/Sugar%20Annual_Managua_Nicaragua_3-15-2013.pdf> [accessed 01 November 2013].

2 0 0 9 0 0 5 1 8 - P a g e | 5
Superior de la Empresa Privada en Nicaragua), an organisation of which Carlos Pellas
Chamorro belongs to the Junta de Consejeros][14
. COSEP is a powerful organisation
consisting of major Nicaraguan conglomerates set up to strengthen private business in
the country][15
. The importance of the Grupo Pellas in relation to the economy of country
cannot be overlooked.
However, according to the World Health Organisation (WHO), more than 16,000 men
have died of kidney failure in Central America between 2005 and 2009][16
. Moreover,
according to an article by Sasha Chavkin, more men are currently dying from CKDu
than from HIV/AIDS, diabetes and leukemia combined][17
. In the Chichigalpa region of
Chinandega in Nicaragua where the Ingenio San Antonio Mill operates in particular,
men as young as 21 have died from the disease.
]
Chronic Kidney Disease was first
recorded in the region 30 years ago and, in the past decade alone has accounted for 46%
of total male deaths and 73.3% of deaths of males aged 34-54[18
. Mortality due to CKD in
Chichigalpa (187.1 per 100,000) was almost 8 times higher than the national
Nicaraguan rate (23.5 per 100,000)][19
.
14 'Indice' en la Revista del Consejo Superior de la Empresa Privada: Nicaragua Empresaria, 5 (Noviembre/Diciembre 2012), pp
5.
15 Spalding, R. J. (1994) Capitalists and Revolution in Nicaragua: Opposition and Accommodation, 1979-1993. UNC Press Books:
North Carolina, pp 200.
16 Chavkin, S. 'CKD: The Killer Still at Large Despite Worldwide Hunt', Sunday Times (23 September 2012), pp 16.
17 Chavkin, S. and Greene, R. 'Thousands of Sugar Cane Workers Die as Wealthy Nations Stall on Solutions', The Center for
Public Integrity (12 December 2011) <http://www.publicintegrity.org/2011/12/12/7578/thousands-sugar-cane-workers-die-
wealthy-nations-stall-solutions> [accessed 14 January 2014].
18 Los Registros de Defunción de la Oficina del Alcaldía, Chichigalpa, Chinandega, Nicaragua.
19 Kurzrok, M. 'Trends in Chronic Kidney Disease-Attributable Mortality in Chichigalpa, Nicaragua from 2002-2012' en el 141a
APHA Reunión Annual (November 2-November 6, 2013).

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There are three parties who currently have the power to address the CKDu epidemic in
Chinandega: the Ingenio San Antonio, the international community and the Nicaraguan
Government. The aim of this report is to investigate the extent of each party's role in the
problems identified. It will evaluate the power of each party to affect change and
compare with its willingness to take action in addressing the epidemic in order to
establish the Government's role in perpetuating CKDu in the community of La Isla,
Nicaragua.
2. Chronic Kidney Disease of Unknown Aetiology (CKDu)
There is much debate over the causative factors of Chronic Kidney Disease (CKDu) and

2 0 0 9 0 0 5 1 8 - P a g e | 7
so far experts cannot determine any one origin][20][][
. According to epidemiologic studies,
Chronic Kidney Disease (CKD) is typically associated with hypertension, diabetes, use of
nephro-toxic drugs and obesity, and therefore is generally more prevalent in wealthier
nations][21
. Chronic Kidney Disease causes a decrease in kidney function and eventual
renal failure and is treated in one of three ways: transplant, hemodialysis or peritoneal
dialysis (PD).
In developed countries, PD is normally the treatment option recommended for patients
who are otherwise healthy, hemodialysis for otherwise vulnerable or older patients][22
.
These measures are typically short term until the patient can access a kidney transplant,
but it is possible for dialysis treatments to maintain patients indefinitely][23
. There are 5
stages of Chronic Kidney Disease, kidney function being normal during stage 1 and stage
5 being classified as 'end-stage' where the patient is likely to die without an immediate
transplant][24
.
20 Jayatilake, N., Mendis, S., Maheepala, P., Mehta, F. R. 'Chronic Kidney Disease of Unknown Aetiology: Prevalence and
Causative Factors in a Developing Country', BMC Nephrology, 14.180 (2013), 1471-2369.
][ Torres, C., Aragon, A., Gonzalez, M., Lopez, I., Jakobsson, K., Elinder, C. G. [...] Wesseling, C. 'Decreased Kidney Function of
Unknown Cause in Nicaragua: A Community-Based Survey', American Journal of Kidney Diseases, 55.3 (2010), 485-96.
][ O’Donnell, J. K., Tobey, M., Weiner, D. E., Stevens, L. A., Johnson, S., Stringham, P. [...] Brooks, D. R. 'Prevalence of and Risk
Factors for Chronic Kidney Disease in Rural Nicaragua', Nephrol Dial Transplant, 28.12 (2010), 815-22.
21 Zhang, L., Zhang, P., Wang, F., Zuo, L., Zhou, Y., Shi, Y. [...] Wang, H. 'Prevalence and Factors Associated With CKD: A
Population Study From Beijing', American Journal of Kidney Diseases, 51.3 (2008), 373-84.
22 Finkelstein, F. O., Story, K., Firanek, C., Barre, P., Takano, T., Soroka, S. [...] Mendelssohn, D. 'Perceived Knowledge Among
Patients Cared for by Nephrologists About Chronic Kidney Disease and End-Stage Renal Disease Therapies', Kidney
International, 74 (2008), 1178–84.
23 Agraharkar, M., Nair, V., Patlovany, M. 'Recovery of Renal Function in Dialysis Patients', BMC Nephrology, 4.1 (2003), 9.
24 Higgins, R. (2009) Vital CKD: Keeping Kidneys Healthy. Class Publishing Ltd: London, pp 30-32.

2 0 0 9 0 0 5 1 8 - P a g e | 8
However, the Chronic Kidney Disease which is being discovered across rural
communities in Central America, Sri Lanka and India has been established by experts as
being of 'unknown aetiology' - commonly referred to as CKDu. The causes of CKDu, a
disease which appears predominantly in developing countries, are not quite clear. Some
experts have identified occupational and environmental causative factors, such as
exposure to heavy metals and pesticides][25
. Studies from Nicaragua and Central America
have suggested increased risks for agricultural workers - particularly in sugar cane
plantations - due to sustained strenuous labour in hot temperatures and severe
dehydration][26
. All sufferers of CKDu have in common an extremely rare form of kidney
damage known as tubule-interstitial disease][27
, a phenomenon which is consistent with
severe dehydration and toxic poisoning][28
.
3. Role of Sugarcane Plantation
3.1 Working Conditions
25 Jayatilake et al. 'Chronic Kidney Disease of Unknown Aetiology: Prevalence and Causative Factors in a Developing Country'.
26 Torres et al. 'Decreased Kidney Function of Unknown Cause in Nicaragua: A Community-Based Survey'.
27 O’Donnell et al. 'Prevalence of and Risk Factors for Chronic Kidney Disease in Rural Nicaragua'.
28 Jennette, J. C. (2007) Heptinstall's Pathology of the Kidney, Volume 1. Lippincott Williams & Wilkins: Philadelphia, pp 412-14.

2 0 0 9 0 0 5 1 8 - P a g e | 9
According to research carried out by La Isla Foundation, several violations of working
conditions are taking place in the ISA Mill, a potential cause in the perpetuation of
CKDu amongst the workers. A study published by the Pacific Institute of Resource
Management found that
minimum wage laws are ignored, with the average [$8 USD] daily
wage only granted after working more hours than allowed by law.
The average wage does not rise over [$70 USD] monthly, and is
insufficient for a family to cover basic essentials.][29
Sugar cane cutters work on a quota system where they are paid dependent on the
amount of sugar cane they cut each day][30
. As a result, sugar cane cutters can work up to
10 or even 12 hours per day without being paid overtime in an effort to provide for their
families. On average, workers cut cane for about 28 or 29 days per month and, due to
the unskilled nature of the work, must always be available to the landowner or risk being
replaced][31
.
Harvest season normally runs from November to May, lasting around 24 – 26 weeks][32
.
During this time, most sugar cane workers work 7 days per week, up to nine and a half
hours per day, cutting around 5 to 7 tons of sugarcane daily. Pay rates per ton is around
29 'The agrofuels industry in Central America', en The Free Library <http://www.thefreelibrary.com/The agrofuels industry in
Central America.-a0199069777> [accessed 09 November 2013].
31 'The agrofuels industry in Central America'

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$0.90 USD. Moreover, due to bonus incentives, many workers attempt to cut up to 13
tons of cane per day, and as a result do not take sufficient breaks in order to rehydrate.
At the ISA Mill, temporary workers, hired solely for the harvest season, account for over
45% of the total workforce and 85% of the field workforce. In this way, these workers
largely depend on harvest season to feed their families for the entire year. This work is
carried out in open fields, with temperatures reaching almost 40 degrees Celsius][33
. Dr
Richard Johnson, a professor who specialises in renal diseases at the University of
Colorado believes that chronic dehydration is a factor in the occurrence of CKDu][34
.
Minimum wage regulations are governed by Ministerial Accord JCHG-010-09-08.
Currently, the minimum wage for field workers equates to around $0.30 USD per hour,
$2.38 USD per day and around $71.42 USD each month][35
. Field workers are also given
a food stipend under article 202, section A of the Labour Code][36
. However, 90% of
sugarcane workers are subcontracted and, as a result, sugar companies are not legally
responsible for labour contract provisions, according to a study by Profesionales para la
Auditoria Social Empresarial (PASE)][37
.
33 'Anatomy of a Riot', informe por Fundación La Isla (2013) <http://laislafoundation.org/wp-
content/uploads/2013/04/AnatomyOfARiotFullReport.pdf?8a2ea7> [accessed 09 November 2013].
34 Naggiar, S. 'Chronic kidney disease: 'Silent killer' may have multiple triggers', NBC News (16 October 2012)
<http://investigations.nbcnews.com/_news/2012/10/16/14142149-chronic-kidney-disease-silent-killer-may-have-multiple-
triggers?lite> [accessed 09 November 2013].
35 'Acuerdo Ministerial JCHG-010-09-08' por el Gobierno de Nicaragua
<http://rrhh.uni.edu.ni/sitio/docs/mitrab/sala_minimo/sm200810.pdf> [accessed 09 November 2013].
36 'Ley Número 185, Código del Trabajo, Título 8, Capítulo 13, Artículo 202', por el Gobierno de Nicaragua
<http://www.ilo.org/dyn/natlex/docs/WEBTEXT/45784/65050/S96NIC01.htm> [accessed 09 November 2013].

2 0 0 9 0 0 5 1 8 - P a g e | 11
Labour Laws in Nicaragua are very specific about working conditions. For example, the
Political Constitution of Nicaragua stipulates that workers have the right to working
conditions that ensure “physical integrity, health, hygiene and reduction of occupational
hazards”][38
. Moreover, Article 100 of the Nicaraguan Labour Code specifies that
employers must ensure they take all necessary measures to “effectively protect the life
and health of their workers”][39
. There also exist international obligations for the
provision of safe working conditions under International Labour Organisation (ILO)
treaties amongst others][40
.
It may be argued that the workers themselves also have a responsibility to ensure they
have the adequate rest and rehydration required for this type of strenuous labour.
However, it cannot be denied that the workers lack the level of education that the
Government and plantation owners have. A 2001 census by the Nicaraguan Government
states that, "27% of the urban population have less than 4 years of education, compared
with 58% of rural areas." According to the report, almost 70% of the population of the
Pacific coast have had only 6 years of schooling][41
. Although the sugarcane company
itself has the responsibility of adhering to working condition regulations, it is clear that
the current Government in Nicaragua also has a role in failing to enforce these
obligations. Regardless of the causes of CKDu, it is clear that these violations of safe
38 'Constitución Política de la República de Nicaragua, Capítulo V – Derechos Laborales, Artículo 82', por el Gobierno de
Nicaragua <http://www.ineter.gob.ni/Constitucion%20Politica%20de%20Nicargua.pdf> [accessed 09 November 2013].
39 'Ley Número 185, Código del Trabajo, Título 5, Capítulo 1, Artículo 100', por el Gobierno de Nicaragua.
40 'International Covenant on Economic, Social and Cultural Rights', por los Naciones Unidos Derechos Humanos
<http://www.ohchr.org/EN/ProfessionalInterest/Pages/CESCR.aspx> [accessed 09 November 2013].
41 'Instituto Nacional de Estadísticas y Censos INEC', por el Gobierno de Nicaragua, pp 51.
<http://www.inide.gob.ni/bibliovirtual/publicacion/indbas2001.pdf> [accessed 23 January 2014].

2 0 0 9 0 0 5 1 8 - P a g e | 12
working practices has a detrimental effect on the health of the workers.
3.2 Food Stipends
It is undeniable that dialogue is an important factor in discovering the causes of CKDu.
However, there is evidence to support the fact that ISA is attempting to prevent the
affected workers from speaking out. According to Article 5 of Ministerial Accord JCHG-
015-11-08, "Employers who are unable to provide cooked meals must pay workers the
sum of C$22.50 [$0.90 USD] per day."][42
Moreover, Article 82 of the Nicaraguan
Constitution states that "Workers have the rights to working conditions which ensure, in
particular: (2) to be paid in legal tender in their workplace. (3) The minimum wage and
social benefits are not exchangeable."] [43
This is reinforced by Article 86 of the Labour
Code in that
Wages will be paid in legal tender [...] In no case may the payment
be made in merchandise, tickets, tokens, or other representative
items intended to replace currency.] [44]
As stated before, at the ISA plantation, wages fall below the minimum living wage[45
and
42 'Acuerdo Ministerial JCHG-015-11-08', por el Gobierno de Nicaragua
<http://www.mitrab.gob.ni/documentos/acuerdos/acuerdos-2010/AcJCHG-015-11-08.pdf/view> [accessed 13 November
2013].
43 'Constitución Política de la República de Nicaragua, Capítulo V – Derechos Laborales, Artículo 82', por el Gobierno de
Nicaragua.

2 0 0 9 0 0 5 1 8 - P a g e | 13
for many families wages are supplemented by food baskets provided by the company] [46
.
Many workers depend on these food baskets to meet the needs of their families.
However, according to a report by the La Isla Foundation, in July of 2012, 13 workers
contacted the Foundation after they had their food baskets revoked for participating in
union activities. The report argues that
Given that food baskets are distributed by ISA only to those who
work at ISA, these food baskets should be regarded as non-
monetary compensation intended to replace the currency
necessary to provide a living wage.][47]
In this way, we can see the provision of food baskets as a replacement for a living wage
violates Articles 82 of the Nicaraguan Constitition[48
and Article and 86 of the Labour
Code][49
. Moreover, the revocation of these food baskets as a reaction to workers'
participation in union activities constitutes a violation of freedom of association laws]
[50
and impedes progress on the discovery of the causes of CKDu.
45 Weber, C. (2006) Visions of Solidarity: U.S. Peace Activists in Nicaragua from War to Women's Activism and Globalization.
Lexington Books: New York, pp 12.
46 'Anatomy of a Riot', pp 9.
48 'Constitución Política de la República de Nicaragua, Capítulo 5 – Derechos Laborales, Artículo 82', por el Gobierno de
Nicaragua.
50 'Constitución Política de la República de Nicaragua, Título 4, Capítulo 1 – Derechos Individuales, Artículo 30', por el Gobierno
de Nicaragua.

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3.3 Freedom of Association Violations
Fear of termination of employment from ISA is another factor which prevents workers
from speaking out, which is both a freedom of association violation and a setback for
research into CKDu. Article 30 of The Political Constitution of the Republic of Nicaragua
states that "Nicaraguans have the right to freely express their beliefs in public or private,
individually or collectively, in oral, written or any other form."] [51
Additionally,
according to Article 87,
Full labour union freedom exists in Nicaragua. Workers may
organise voluntarily in unions, which shall be constituted in
conformity with the law. No worker is obligated to belong to a
particular union, nor renounce its belonging.][52]
Articles 49[53
and 53] [54
of the Constitution also reinforce political rights in terms of
freedom of organisation and the right to peaceful assembly without prior permission.
The revocation of food baskets based on the workers' union affiliations is a clear
de Nicaragua.
de Nicaragua.
de Nicaragua.
54 'Constitución Política de la República de Nicaragua, Título 4, Capítulo 2 – Derechos Individuales, Artículo 53, por el Gobierno
de Nicaragua.

2 0 0 9 0 0 5 1 8 - P a g e | 15
violation of all four laws.
Participation in independent research and communication with the media in relation to
CKDu has also caused ISA to revoke the workers' food baskets. In February 2010, the La
Isla Foundation claims that "10 workers were fired for their participation in a cross-
industrial medical study led by the Center for the Investigation of Environmental and
Occupational Health (CISTA)." There have also been reports of police, local government
representatives and ISA company presence at wakes and funerals of those who have
died from CKDu. The La Isla Foundation's report indicates that the organisation has
received reports that police, government representatives and
company officials appear at services to threaten family members
with reprisals should they protest, and to offer them payment for
compliance.] [55]
In this way, we can see that both the Nicaraguan Government and the Ingenio San
Antonio both play a role in the violation of freedom of association laws of the people of
Chichigalpa, which makes it significantly more difficult for research to be conducted
into the causes of the disease.
3.4 Environmental Issues
According to a research paper about causes of CKDu in Sri Lanka, cadmium from

2 0 0 9 0 0 5 1 8 - P a g e | 16
pesticides and fertilizers may be a significant cause of the disease, meaning that ISA may
have a significant role in the perpetuation of the disease. In the study, it is claimed that
the well water the workers drink from could be contaminated with "high concentrations
of cadmium and other toxic compounds than wells situated in home gardens." Also,
a study on the potential impact of heavy metals on groundwater as
a result of fertilizer use suggests significant groundwater pollution
from Cd [cadmium], Se [selenium], Mo [molybdenum] and U
[uranium] caused as a result of long-term use of phosphate
fertilizers.[56]
Another study carried out in Sri Lanka found that "a significantly higher cadmium
concentration was also seen in the nails of CKDu cases" and "arsenic levels were
significantly higher in CKDu cases."
Moreover, workers in the area experienced urinary excretion of cadmium, considered by
the authors to be "a reliable indicator of cumulative long-term exposure to
cadmium."[57
Significantly, a report by Boston University at the ISA Mill reported that
we found strong evidence in our review of the medical literature
that chemicals used by ISA currently or in the past are associated
56 Wanigasuriya, K. P., Peiris-John, R. J., Wickremasinghe, R. 'Chronic Kidney Disease of Unknown Aetiology in Sri Lanka: Is
Cadmium a Likely Cause?', BMC Nephrology, 12.1 (2011), 32.
57 Jayatilake et al. 'Chronic Kidney Disease of Uncertain Aetiology: Prevalence and Causative Factors in a Developing Country'.

2 0 0 9 0 0 5 1 8 - P a g e | 17
with acute kidney damage in humans or animals under certain
exposure scenarios.
The report also states that
Overall, it seems likely that exposure to agrichemicals has
decreased over time and that PPE [personal protective equipment]
is controlling exposure to agrichemicals to some extent, but the
high frequency of agrichemical use, poor decontamination
procedures, and the use of respirator cartridges not recommended
for use with organic vapors likely result in exposures to
agrichemicals that vary by job and chemical.][58
The Boston University report also found that
although heat stress is not a recognized cause of CRI [CKDu], it is
associated with volume depletion and muscle damage
(rhabdomyolysis), both of which are recognized susceptibility
factors for acute kidney damage.
The air temperatures were found to range between 28.6°C and 40.1°C in the fields,
which would require "workers performing heavy work (such as cutting sugar cane) to
58 McClean, M., Laws, R., Ramirez, R. O., Brooks, D. 'Industrial Hygiene/Occupational Health Assesment: Evaluating Potential
Hazards Associated with Chemicals and Work Practices at the Ingenio San Antonio (Chichigalpa, Nicaragua)' por el CAO (2010),
pp 44 <http://www.cao-ombudsman.org/documents/FINALIHReport-AUG302010-ENGLISH.pdf> [accessed 07 January 2014].

2 0 0 9 0 0 5 1 8 - P a g e | 18
work for 15 minutes and rest for 45 minutes out of each hour" in order to adhere in
order to comply with Permissible Heat Exposure Threshold Limit Values (TLVs)
mandated by the United States Occupational Safety and Health Administration
(OSHA).][59
Additionally, an unpublished study in ISA sugar cane workers found a weight
loss of 2.6 kg in workers who were uneducated regarding the need for rehydration.
Significantly, this study found that there is
strong evidence from our field observations and available reports
that current work practices at ISA could be associated with heat
stress and volume depletion, and strong evidence from our review
of the medical literature that volume depletion and muscle damage
are associated with acute kidney damage in humans or animals.] [60]
In this way, it is clear that working conditions at ISA may indeed cause CKDu, and
therefore the sugarcane plantation may have much more of a role in the perpetuation of
the disease than previously thought.
3.5 Union Affiliations
Another potential setback in the dialogue and research on CKDu are lack of valid union
affiliations, and therefore, lack of job security. Figures from a mill questionnaire in
January 2009 show that temporary workers make up to 85% and 40% of the field and
59 'Industrial Hygiene/Occupational Health Assessment [...]', pp 45.
60 'Industrial Hygiene/Occupational Health Assessment [...]', pp 45-47.

2 0 0 9 0 0 5 1 8 - P a g e | 19
refinery workforce at ISA respectfully. Due to the temporary nature of the work,
according to the study carried out by PASE, subcontracted workers are less likely to
affiliate themselves with a union, meaning that their ability to negotiate better working
conditions is significantly reduced[61
. Moreover, when asked, 85% of workers at ISA
responded that they are not free to organise a union. The study also claims that,
although there still exists unions within sugar refineries in Nicaragua, they have lost
power in recent years and, as a result, many permanent workers have decided to retire
from the unions. Moreover, according to the report, there exists “yellow unions” within
the refinery, consisting of managerial and administrative personnel “in order to clean up
its public image and respond to the questioning of some local actors."][62
In this way, we
can see that in the attempt to avoid blame, ISA may be providing propoganda and
misinformation in current CKDu studies.
61 'Nicaraguan Sugar: A Macro View of Today’s Industry', informe por Specialized Technology Resources Inc, pp 15.
<http://assets.coca-colacompany.com/10/58/7b94d83d4c25a4a3bb5eb919649e/NicaraguaSugarIndustry-
AMacroLevelReport012309.pdf> [accessed 09 January 2014].

2 0 0 9 0 0 5 1 8 - P a g e | 20
4. Role of the International Market
4.1 US and EU Imports
US and EU demand for Central American sugar has the potential to affect working
conditions in the plantations, and therefore perpetuate CKDu. In 2011, the US imported
more than 330,000 metric tonnes of sugar from the Pacific Coast of Nicaragua, Costa
Rica and El Salvador – where CKDu is also being found amongst sugarcane cutters. This
figure represents 23% of all total raw sugar imports to the US][63
. According to Central
American Data, in September 2013, seven EU buying houses participated in an auction
listing 9,000 tonnes of Nicaraguan sugar, 8000 tonnes from Honduras and 25,000
tonnes from Guatemala. The lot sold to an EU buying house for $480 USD per tonne][64
.
An article published by the Center for Public Integrity stated that the International
Consortium of Investigative Journalists (ICIJ) were told by a US delegate of the Centers
63 Sanders, K. and Seville, L. R. 'Mystery Kidney Disease Decimates Central American Sugarcane Workers', NBC News (16
October 2012) <http://investigations.nbcnews.com/_news/2012/10/16/13866856-mystery-kidney-disease-decimates-central-
america-sugarcane-workers?lite> [accessed 14 January 2014].
64 '42,000 Tons of Sugar Sold to EU', en Central American Data Online
<http://www.centralamericadata.com/en/article/home/42000_Tons_of_Sugar_Sold_to_EU> [accessed 14 January 2014].

2 0 0 9 0 0 5 1 8 - P a g e | 21
for Disease Control and Prevention that “the US opposed mentioning CKD to keep the
focus on diabetes, heart disease and cancer."][65
Moreover, at a UN summit of health
ministers in Mexico City in February 2012, the representative of El Salvador, Isabel
Rodriguez reached out to the International Community for help in dealing with the
CKDu epidemic in Central America. However, according to Rodriguez, the US
delegation not only refused to include the disease on a list of the continent's most
prominent chronic illnesses, but also refused to accept any suggestion that the epidemic
may be caused by toxic poisoning] [66
. The fact that the EU and US have knowledge about
the problem and continue to buy sugar from Central America has a detrimental effect on
CKDu.
4.2 The World Bank
Another participant in the perpetuation of CKDu is the World Bank. In 2006, the
International Finance Corporation (IFC), an investment arm of the World Bank Group
provided a loan of USD $55 million to Ingenio San Antonio for the expansion of its
plantation and the promotion of the biofuels industry in Nicaragua. This caused the
communities of Leon and Chinandega to write to the Compliance Advisor Ombudsman
(CAO) citing concerns over the poor labour conditions, pesticide use and the association
between NSEL and CKDu][67
. It was this complaint that sparked an investigation by
65 Chavkin, 'Thousands of Sugar Cane Workers Die as Wealthy Nations Stall on Solutions'.
67 'Stakeholder Assessment Report Regarding Community and Civil Society Concerns in Relation to Activities of the
Nicaragua Sugar Estates Limited (NSEL), Nicaragua', informe por el CAO (2008), pp 1-2 <http://www.cao-
ombudsman.org/cases/document-links/documents/AssessmentReportNSEL10_Dec_2008.pdf> [accessed 17 January 2014].

2 0 0 9 0 0 5 1 8 - P a g e | 22
CAO, led to the Boston University report and marked the beginning of a dialogue
between ASOCHIVIDA and NSEL][68
. However, in 2008, a USD $50 million loan was
approved by the IFC for Chinandega-based Ingenio Monte Rosa (IMR)][69
, another
sugarcane plantation found to have high levels of CKDu in cane cutters and poor
working conditions][70
. Prior to the loan being approved, the IFC composed an
Environmental and Social Review Summary regarding potential issues at the mill which
were required to be rectified before the IMR would be eligible for the loan. CKDu
amongst workers was not mentioned anywhere in this report][71
. In this way, the World
Bank either failed to research working conditions properly, or ignored the epidemic and
proceeded to give money to a company whose working conditions could cause a deadly
disease.
4.3 Promotion of Biofuels
International promotion of biofuels could have a detrimental effect on the workers
diagnosed with CKDu as ethanol production at ISA is prioritised over the health of the
workers. Due to an increased focus on renewable energy, a policy known as the
68 'Final Scoping Study Report Epidemiology of Chronic Kidney Disease in Nicaragua', informe por el CAO (2009), pp 154-155
<http://www.cao-ombudsman.org/cases/document-
links/documents/03H_BU_FINAL_report_scopestudyCRI_18.Dec.2009.pdf> [accessed 17 January 2014].
69 'Summary of Proposed Investment' de la Corporación Financiera Internacional
<http://ifcext.ifc.org/ifcext/spiwebsite1.nsf/ProjectDisplay/SPI_DP26009> [accessed 17 January 2014].
70 Brace, B. 'Ethical Sugar' en Sucre Ethique (5 July 2007) <http://www.sucre-ethique.org/For-sugar-mill-workers-in> [accessed
17 January 2014].
71 'Environmental and Social Review Summary' de la Corporación Financiera Internacional
<http://ifcext.ifc.org/ifcext/spiwebsite1.nsf/78e3b305216fcdba85257a8b0075079d/5dfbf7248fe3fe4e852576ba000e2a34?
opendocument> [accessed 17 January 2014].

2 0 0 9 0 0 5 1 8 - P a g e | 23
Renewable Fuel Standard (RFS) calls for an increase in the use of biofuels in America.
As a result, sugarcane biofuel has become an emerging industry, with the US
Environmental Protection Agency (EPA) claiming that Brazilian sugarcane ethanol
reduces greenhouse gases by 61%][72
. In 2007, after ISA had made its first shipment of
ethanol, Paul Trivelli, the U.S Ambassador in Nicaragua stated that the ISA had
embraced "the potential to develop the industry and the positive aspects of biofuels."
The following year, according to Trivelli, the US State Department saw Nicaragua as a
"high priority country" for the production of sugarcane ethanol][73
. This promotion of
biofuels by the International Market seems to have overshadowed the requirements for
workplace conditions set out in fundamental treaties of the International Labour
Organization (ILO) such as the Discrimination (Employment and Occupation)
Convention 1958 (No. 111)][74
and the Freedom of Association and Protection of the
Right to Organise Convention 1951 (No. 87)][75
. The International community also has
the obligation to ensure that the terms of the International Covenant on Economic,
Social and Cultural Rights are upheld within Nicaraguan industry][76
. Regardless of the
recent prioritisation of biofuels, the international community has the responsibility to
ensure that suppliers do not expose workers to inadequate conditions such as those
72 'US Policy Overview' en Sugarcane <http://sugarcane.org/global-policies/policies-in-the-united-states/us-biofuel-
policy/rfs/policy-overview> [accessed 19 January 2014].
74 'NORMLEX Information System on International Labour Standards, Ratifications for Nicaragua' del Organización
Internacional del Trabajo <http://www.ilo.org/dyn/normlex/en/f?p=NORMLEXPUB:12100:0::NO::P12100_ILO_CODE:C111>
[accessed 19 January 2014].
75 'NORMLEX Information System on International Labour Standards, Ratifications for Nicaragua' de la Organización
Internacional del Trabajo <http://www.ilo.org/dyn/normlex/en/f?p=NORMLEXPUB:12100:0::NO::P12100_ILO_CODE:C087>
[Accessed 19 January 2014].
76 'International Covenant on Economic, Social and Cultural Rights'

2 0 0 9 0 0 5 1 8 - P a g e | 24
which potentially cause CKDu.
5. Role of the Nicaraguan Government
5.1 Lack of Access to Healthcare
It can be said that the Nicaraguan Government's role in this problem is significant, in
terms of both lack of enforcement of regulations to prevent CKDu as well as lack of
provision of healthcare facilities and employment regulations after the disease has been
contracted. A report by the La Isla Foundation found that there is limited access for
sugarcane workers to healthcare facilities. Moreover, these clinics suffer from a lack of
supplies and lack of a nephrologist. In most cases it takes around 1 hour to walk to the
nearest medical clinic in Chichigalpa, and from here the workers need to catch a bus or a
taxi to get to the nearest hospital in Chinandega][77
.
The ISA sugarcane plantation has a policy of testing each of its workers’ creatinine levels
before the start of each harvest season and if, at any time, the worker experiences
trouble in the field. Creatinine levels are indicative of kidney health, and this practice
could be a good preventative measure against CKDu. However, the plantation uses the
results of the test to determine whether or not to continue to employ the workers.
Should the workers display high creatinine levels, they are subsequently fired and lose
77 'Anatomy of a Riot', pp 10-11.

2 0 0 9 0 0 5 1 8 - P a g e | 25
access to healthcare at the plantation hospital][78
.
The Nicaragua Government have regulations in place to allow equal access to healthcare
to all its citizens, such as the Ley General de Salud][79
. It is even written into the
constitution that “The responsibility lies with the State to coordinate and organise
health programmes and services”][80
. However, no action is being taken against the
Grupo Pellas to prevent the unethical dismissal of the workers, an act which is then
effectively procluding them from accessing proper healthcare systems and therefore
perpetuating the occurrence and mortality of CKDu sufferers.
5.2 Riots and Police Brutality
Suppression of riots and police brutality towards those protesting lack of dialogue on
CKDu is another way in which the Nicaraguan Government perpetuates this disease. On
March 18 2013, workers from the ISA plantation and their families staged a peaceful
protest in the Nicaraguan capital of Managua in an attempt to draw attention to the
CKDu epidemic in Chichigalpa. After protesting at the Grupo Pellas Headquarters, as
well as at the Instituto Nacional de Seguridad Social, the families returned to
Chichigalpa, where they staged a legal roadblock. The roadblack is a recognised form of
protest in Nicaragua and video footage taken at the scene supports the assertion that the
79 'Ley General de Salud', por el Gobierno de Nicaragua <http://legislacion.asamblea.gob.ni/Normaweb.nsf/
($All)/FF82EA58EC7C712E062570A1005810E1?OpenDocument> [accessed 10 November 2013].
80 'Constitución Política de la República de Nicaragua, Capítulo 3 – Derechos Sociales, Artículo 59, por el Gobierno de
Nicaragua.

2 0 0 9 0 0 5 1 8 - P a g e | 26
protesters complied with Government regulations, periodically allowing cars to pass][81
.
However, on arrival of the Nicaraguan police, eyewitness accounts cite excessive use of
force against the protesters. Despite the fact that the roadblock was compliant with the
law, tear gas canisters were fired into a crowd of less than 200 people, including women
and children who were retreating from the conflict. After people had dispersed and
returned home, police began to arrive at houses, arresting civilians. Protesters,
bystanders and even children were severely beaten by police forces during this riot][82
.
One unidentified female, aged 27, later said: “I knew some of the arrested. They were all
young and all beaten. One of them told [the police] that he would report them and they
beat him more.”][83
In this way, the excessive force of Government officials can only be seen as an attempt to
repress the freedom of speech of the citizens of Chichigalpa who were attempting to
draw attention to the situation regarding CKDu in their community. The rights of
freedom of expression and freedom of assembly are set out in several treaty obligations
ratified by the Government, including the Universal Declaration of Human Rights][84
and
the American Convention on Human Rights] [85
. Despite the fact that the Government
81 'Nicaragua: Peaceful protest turns violent, former sugarcane workers demand rights' en Climate Connections (22 March
2013) <http://climate-connections.org/2013/03/22/nicaragua-peaceful-protest-turns-violent-former-sugarcane-workers-
demand-rights/> [accessed 19 November 2013].
84 'Declaración Universal de los Derechos Humanos' de los Naciones Unidos <http://www.un.org/en/documents/udhr/>
[accessed 19 November 2013].
85 'Convención Americana sobre Derechos Humanos' por la Organización de los Estados Americanos

2 0 0 9 0 0 5 1 8 - P a g e | 27
has clearly and publicly recognised that freedom of expression is essential to a
democratic society, the actions of the police force clearly display a tendency towards
suppression of the citizens of Nicaragua in terms of their freedom to talk about CKDu.
5.3 Government Opposition to La Isla Foundation
International groups who work in the area and reach out to the international community
for support and publicity about CKDu are also vital in order to find the causes of the
disease. La Isla Foundation was formed in Chichigalpa, Nicaragua in 2008 by the
independent American documentary filmmaker Jason Glaser][86
. However, staff at the La
Isla Foundation has reported high incidences of mistrust from Government officials.
According to Glaser himself, some sugar cane industry representatives and Government
officials have accused the organisation of various misdeeds, such as being a front for
drug trafficking. Due to the fact that the ISA has started exporting large amounts of
biofuels, Glaser has also been accused of being a representative of the oil industry trying
to destroy the biofuel market.
Moreover, the organisation has reportedly received numerous threats from Government
representatives and the sugar cane workers themselves have also been discouraged from
working with the La Isla Foundation. In an interview with Chicago Public Radio, Jason
Glaser said:
<http://www.oas.org/dil/treaties_B-32_American_Convention_on_Human_Rights.htm> [accessed 19 November 2013].
86 'Our Story' por la Fundación La Isla <http://laislafoundation.org/about-us/> [accessed 25 November 2013].

2 0 0 9 0 0 5 1 8 - P a g e | 28
The day after the protest [in Managua] … an Internal State
Security started asking some of my employees whether or not I
was in the CIA, where our money came from, are we trying to
destabilise the Nicaraguan Government?
Attempting to undermine the importance of groups working in the area to improve the
lives of those suffering from CKDu and reduce the high prevalence of the disease in the
area also means that the Government is undermining the importance of the disease][87
.
5.4 Lack of Government Involvement in Dialogue
It is vital that the Government engage the problem in order to start finding solutions for
the workers who are diagnosed with CKDu. In Chichigalpa, there is an organisation
called the Chichigalpa Association for Life - also known as ASOCHIVIDA, made up of
several community leaders and backed by former sugarcane workers as well as the
families of those who have died from CKDu. The aim of ASOCHIVIDA is to gain
compensation for those affected by the CKDu found in the sugar cane cutters. In 2007,
ASOCHIVIDA began working with a Washington-based law firm called Center for
International Environmental Law (CIEL) to file a complaint with the Compliance
Advisor Ombudsman (CAO) of the World Bank Group][88
.
87 'An Apparent Epidemic in Kidney Disease in Sugar Cane Workers in Nicaragua', en Worldview Podcasts, Chicago Public
Radio.<http://podbay.fm/show/272844078/e/1366315291> [accessed 25 November 2013].
88 'Final Scoping Study Report Epidemiology of Chronic Kidney Disease in Nicaragua', pp 6.

2 0 0 9 0 0 5 1 8 - P a g e | 29
As a result, the CAO worked to initiate a dialogue between ASOCHIVIDA and NSEL.
According to a report by Access, an independent mediation platform, this epidemic was
not given proper attention either by the organisations involved or the Government prior
to this process. However, with the help of CAO,
When ASOCHIVIDA achieved the ability to talk to the company
directly, something that hadn’t previously existed, people rallied
behind them as the most likely group to get the compensation they
wanted.][89]
However, the report states that, despite the recognition by both ASOCHIVIDA and
NSEL of the importance of the presence of a Government representative during the
proceedings, the Government repeatedly refused to get involved in the process.
According to the report, despite the CAO's efforts,
The government chose not to participate in the CAO-convened
dialogue process. The absence of this key stakeholder throughout
the process continues to be a challenge to effecting the changes
that the parties to this dialogue hoped for.[90]
In this way, we can see that the Government's lack of involvement had a detrimental
89 Lumerman, P. and Autrey, D. 'Chichigalpa Association for Life and Nicaragua Sugar Estates Ltd', ACCESS, pp 8-9.
<http://accessfacility.org/sites/default/files/ACCESS%20Case%20Story%201%20-%20Chichigalpa%20-%20with%20images.pdf>
[accessed 5 December 2013].
90 'Chichigalpa Association for Life and Nicaragua Sugar Estates Ltd', pp 16.

2 0 0 9 0 0 5 1 8 - P a g e | 30
effect on the mediation process and therefore a detrimental effect on the search for
answers about CKDu.
5.5 Social Security
Social security benefits for diagnosed workers would make it easier for families to cope
with the demands of a chronic kidney problem, and the men affected would be less likely
to die. In 2004, Ley 456 was added to the Labour Code, guaranteeing
comprehensive social security protection and provision of
livelihood in cases of disability, old age, occupational hazards,
sickness and maternity; and to families in cases of death in the
form and manner prescribed by law.[91]
However, sick workers and families of deceased workers still struggle to receive social
security benefits and state pensions.
In order to apply for social security, there are several requirements which are almost
impossible for the sugar cane cutters to meet. Firstly, they are required to have worked a
minimum of 150 weeks in the last 6 years[92
. Normally the workers begin to get sick after
91 'Ley Número 456 - Ley de Adición de Riesgos y Enfermedades Profesionales' por el Gobierno de Nicaragua
<http://www.mitrab.gob.ni/documentos/leyes/Ley456Nic.pdf/view> [accessed 10 December 2013].
92 'Ley Número 539 - Ley de Seguridad Social' por el Gobierno de Nicaragua
<http://legislacion.asamblea.gob.ni/Normaweb.nsf/($All)/C0D9072AD24378630625755B0076D0B9?OpenDocument>
[accessed 10 December 2013].

2 0 0 9 0 0 5 1 8 - P a g e | 31
working for 2 or 3 seasons][93
. To qualify for social security, the men would have to work
for 6 harvest seasons][94
.
Secondly, the workers must prove they were healthy prior to beginning work at the
sugar plantations. Although ISA regularly performs creatinine testing, the workers are
prohibited access to these records due to the fact that the tests are carried out in the
ISA's private clinic, and therefore the medical records are the property of the company]
[95
. Additionally, meeting these criteria does not necessarily guarantee provision of social
security benefits][96
. The fact that the Government makes it difficult to access social
security means that the diagnosed workers often cannot access adequate healthcare and
therefore are more likely to die from the disease.
5.6 Nicaraguan Business Interests
Another factor which potentially perpetuates the incidence of CKDu in Nicaragua are
economic influences. In a research paper published in the Journal of Banking and
Finance, the authors argue that "Government ownership is generally harmful to the
corporate governance of the firm" and that "this finding intensifies as the government's
power increases, and it is specifically linked to central government ownership."][97
After a
96 'Ley Número 539 - Ley de Seguridad Social' por el Gobierno de Nicaragua.
97 Borisova, G., Brockman, P., Salas, J. M., Zagorchev, A. 'Government Ownership and Corporate Governance: Evidence from
the EU', Journal of Banking and Finance, 36 (2012), 2917-34.

2 0 0 9 0 0 5 1 8 - P a g e | 32
recent pact made between COSEP and President Ortega] [98
, Article 98 of the Nicaraguan
Constitution was amended to state that "The principal function of the State in the
economy is to materially develop the country."][99
Monica Baltodano, a legislator with the Movimiento Renovador Sandinista (MRS) says,
“Capital is reaching a direct and very good understanding with the Ortega government.
COSEP’s upper echelons and the finance capitalists are very pleased with the
government, because despite the populist and confrontational discourse Ortega uses
when referring to private enterprise, in practice he doesn’t to touch the central interests
of those groups.”][100
Jason Glaser believes that, in terms of the CKDu problem, “This Government really
hasn’t engaged the problem in a proactive way. The relationship with the major sugar
producer seems to be far too cosy.”][101
Moreover, according to Phil Ryan, in 1981 the
FSLN
would attempt to use 'economic incentives' to induce the
bourgeoisie to continue to produce ... such as Alfredo Pellas, who
98 Montalván, W. 'El Pacto Ortega-COSEP', La Prensa [Nicaragua] (23 September 2013)
<http://www.laprensa.com.ni/2013/09/23/voces/163440-pacto-ortega-cosep> [accessed 23 December 2013].
99 'Constitución Política de la República de Nicaragua, Título 6, Capítulo 1 – Economía Nacional, Artículo 98, por el Gobierno de
Nicaragua.
100 'The FSLN Government Pieces Together Its New International Policy Puzzle', Envio Digital (September
2007)<http://www.envio.org.ni/articulo/3643> [accessed 23 December 2013].
101 'An Apparent Epidemic in Kidney Disease in Sugar Cane Workers in Nicaragua'.

2 0 0 9 0 0 5 1 8 - P a g e | 33
owned the largest sugar mill in the country.] [102]
In this way, we can see that the Sandinista government has a long history with the
Grupo Pellas and with COSEP and that there is a clear conflict of interest in relation to
lack of government intervention in the CKDu epidemic. Former Attorney General
Alberto Novoa believes that
Wherever there is confusion or a conflict of interests between the
state and the government, and the ruling party and the first family,
the situation becomes corrupted. The separation of state and party
is an unfinished task in Nicaragua.[103]
Likewise, Timothy Kuhner argues for the complete separation of state and private
business in order for a democratic society to function. He states that:
The relationship between economic and political inequality is
mutually reinforcing: greater political traction for the wealthy
leads to public policies favorable to the wealthy, which leads to
greater economic inequality, which in turn leads to greater
political inequality, and so on.[104]
102 Ryan, P. (1995) The Fall and Rise of the Market in Sandinista Nicaragua. McGill-Queen's University Press: Montreal, pp 127.
103 Rogers, T. 'Nicaragua's Newest Tycoon? 'Socialist' President Daniel Ortega', Inside Costa Rica (12 October 2009)
<http://insidecostarica.com/dailynews/2009/october/14/centam-091014-04.htm> [accessed 23 December 2013].
104 Kuhner, T. K. 'The Separation of Business and State', California Law Review, 95.6 (2007), 2353-92.

2 0 0 9 0 0 5 1 8 - P a g e | 34
Like this, we can see that ISA owner Grupo Pellas has undue influence over the
Nicaraguan Government, and therefore this could be a factor in the Government's lack
of action regarding CKDu.
6. Conclusion
The question of responsibility with regards to Chronic Kidney Disease of unknown
aetiology in the Pacific coast of Nicaragua is an extremely pertinent one. Having
examined several factors relating to perpetuation of the disease, it is clear that the
Nicaraguan Government, the plantation owners and the international market all have a

2 0 0 9 0 0 5 1 8 - P a g e | 35
role to play with regards to the continuing mortality of the sugarcane cutters.
Although it can be argued that the workers themselves have the responsibility of
adhering to working guidelines, resting and rehydrating regularly, it can also be said
that the workers lack the education level that the plantation owners and Government
posess. Additionally, the quota system implemented by ISA perpetuates the workers'
need to work consistently long hours in order to be able to provide enough income to
sustain their families. It is also unclear at this stage whether heat exposure and extreme
dehydration are the causes of the epidemic due to lack of appropriate research.
Undoubtedly, ISA have committed many violations in terms of working conditions,
contracts, failure in the provision of personal protective equipment, freedom of
association and potential exposure of the workers to agrichemicals. The Grupo Pellas is
a powerful company both in Nicaragua and throughout Central America and a key
contributer to the Nicaraguan economy. However, although it is the Government's
responsibility to regulate private business in any democratic country, the Grupo Pellas is
linked with Daniel Ortega through COSEP, and this provokes a question of conflicting
interests. As Kuhner argues, there must be a complete separation of state and private
business in order for any democratic society to function.
It is true that the international market also has a role to play in the perpetuation of the
disease. Promotion of production of sustainable fuels such as sugarcane ethanol has so
far not been done in a sustainable way. By continuing to award grants to companies with
working condition violations such as ISA and Mill Monte Rosa, the World Bank has

2 0 0 9 0 0 5 1 8 - P a g e | 36
essentially excused the companies' lack of engagement regarding CKDu. In this way, it is
necessary for the international community to promote sustainable development in
countries such as Nicaragua, instead of focusing on short-term economic goals.
Clearly this epidemic has created a significant problem of mortality in one of the poorest
countries in the world. As such, lack of access to appropriate healthcare and job
insecurity after contracting the disease is not only troubling, but a violation of human
rights which the Nicaraguan Government has a responsibility to uphold. Lack of
research into CKDu has primarily caused the perpetuation of this problem, and evidence
suggests that both the Ingenio San Antonio and the Nicaraguan Government themselves
have blocked certain attempts at research and dialogue for fear of CKDu being classified
as an occupational disease. However, it is a primary responsibility of the Nicaraguan
Government to ensure the health and wellbeing of its citizens and its promotion of the
study of the disease could mean that this epidemic could eventually become preventable
for the sugarcane workers both in Nicaragua and throughout Central America.

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