The human cost of sugar
Chronic Kidney Disease (CDKu) is a fatal progressive loss of kidney function. In the last decade alone it has claimed the lives of over 20,000 people in Central America.  The disease has been focused largely in the coastal pacific region, and the majority of those affected have been agricultural labourers.
In Nicaragua: a deadly epidemic
In Chichigalpa in Nicaragua at least 7,000 people have been affected with the disease. The illness in this area is most concentrated in sugar-cane workers - in particular at the Ingenio San Antonio sugar-cane plantation which comprises 40,000 hectares and is owned by Nicaragua Sugar Estate Ltd. NSEL is part of the Grupo Pellas, one of the largest business conglomerates in the Central American region. The largest stakeholder is Carlos Pellas Chamorro; Nicaragua’s first billionaire who by his own account, is politically engaged.
Victims and families of those affected by chronic kidney disease in Chichigalpa have been engaged in a fight for rights that has lasted decades, demanding that the government and employers recognize and accept responsibility for the illness and its grave consequences. They have seen some victories during this struggle. The government now gives pensions to those affected, as well as medical support and dialysis sessions. 
However given the incredible scale and the devastating impacts of the illness in affected communities; where chronic kidney disease is the cause of almost half of all deaths of adult males, workers continue to seek further recognition and responsibility, in particular from employers. They point to the use of chemicals in pesticides, and contamination of the water supply, as contributing causes of the illness, and demand that the industry change its practises to safeguard others from the disease.
Since 2009, representatives of the Nicaraguan Association for those Affected by Chronic Kidney Disease (“ANAIRC”) set up camp in the centre of Managua to turn their protest into a permanent presence. It is because of this that Eat United has got to know this community; operating the rescued food-sharing service with those living in the camp since 2014.
One of the challenges to their protests has been that research has not produced conclusive evidence that links the disease to agro-chemicals. Indeed, in a press note in 2013 the Ingenio San Antonio indicates not only is there no evidence to connect the chemicals it uses with CKD, but that it is exemplar in upholding industry standards for labour conditions, and engages in rigorous monitoring of water quality. The note highlights that as well as the benefits it offers its employees, the company has also supported workers’ associations, providing micro-credit schemes and income-generating programs for those affected. Workers’ testimonies from 2009 re-iterate the support that NSEL provides for its workers.
Widening the Lens: improving workers’ conditions and changing public policy
Chronic kidney disease is not only affecting workers in Nicaragua. There have been confirmed epidemics across Centroamerica, Egypt and India, as well as reported epidemics in other countries in South America, Africa and South-east Asia. Additionally, in some cases if affects people who havenot been engaged in heavy manual labour.
In their 2013 press note , Nicaragua Sugar Estate Ltd highlights a quote from Meg Taylor (Vice President and CAO of the World Bank Group), to the effect that given the reach and scale of the illness, a long-term solution would mean investigating the causes at a regional level and changes to public policy. This may be the crux of the matter for the ex-sugar cane workers. It will be difficult to get any individual company to change or assume responsibility for the disease without wider evidence and an international movement driving changes to industry.
In order to improve conditions for labourers globally, change industry standards and influence public policy there needs to be clearer evidence of what drives the disease and how to prevent it.
La Isla Network (LIN) is an NGO dedicated to eradicating Chronic Kidney Disease that is helping to answer this call. While it now works internationally to generate evidence-driven solutions to the epidemic, its roots and its name come from its work with the “Isla de Viudas”; the infamous “Island of Widows” in Chichigalpa, Nicaragua- named because of the huge percentages of the male population killed by the disease.
A large part of LIN's work is in generating independent evidence about what causes the disease. For this reason it calls the disease “CDKu”, Chronic Kidney Disease of undetermined causes. Current hypotheses are that CDKu is caused by multiple factors. Heat stress and dehydration due to excessive workload cause repeated kidney injury – and environmental exposures to toxins, (naturally occurring or introduced like fertilizers or pesticides) may be drivers as well. 
La Isla Network also drives change in labour conditions, working with employers to make sure that employees, who are regularly exposed to temperatures above 32°C (89.6°F) and sometimes exceeding 42°C (107.6°F), should have access to water, rest and shade. The Ingenio San Antonio is now one of the companies that have joined forces with LIN to implement their “WE” program for workers health. The results from these programs, combined with independent research, help the network to influence industry standards and push for policy changes globally.
What does climate change mean for CKDu?
As the climate warms, the exposure of agricultural labourers to heat stress and dehydration becomes more intense. Additionally, more labourers will be exposed to higher temperatures. Given the inadequacy of current responses to the epidemic, as Carlos Martinez puts it: “Could agricultural workers in Central America simply be climate canaries, the first to be impacted by conditions that will spread?” 
The illness and its relation to exposure to heat and toxins are still not fully understood, it may take time for companies and governments to respond to this public health crisis. Meanwhile, as temperatures rise, labour conditions get tougher.
CKDu has already claimed more lives than Ebola. We can only hope that awareness of this danger, and preventative responses in labour conditions and policy, spread faster than the disease.