PHRGE Revisited: A public health epidemic among Nicaraguan sugarcane workers

I’ve always hated being a student, I just I always saw it as a necessary evil to get where I wanted to go.  That being said, there are times where I’ve wished I was back in law school, often so I could justify going on co-op again!  So during a recent period of unemployment, that’s exactly what I did, and the road I took kept leading me back to my time as a PHRGE fellow.

For my last NUSL co-op (in fall 2009), I served a PHRGE fellow at Oxfam America in Boston, in their Private Sector Department (PSD).  The two projects I worked on the most during my time there was the PSD’s Access to Medicines project, and Oxfam America’s pilot of their Poverty Footprint methodology.  The Access to Medicines project allowed me to expand on my understanding of legal interventions related to pharmaceuticals – something I had started to work on during my first co-op at the Illinois Attorney General’s office, working on multi-state pharmaceutical litigation.  At Oxfam, it was interesting to see the interaction with pharmaceutical companies in a global context, and how dynamics in the private sector worked in addressing the need for access to medicines in developing countries.

The second project, the Poverty Footprint, would have more far-reaching impact on my current work, although I didn’t realize it at the time.  At the time, Oxfam was piloting this methodology to evaluate how a company’s supply and production value chains impacted the lives of workers and communities within those value chains.  The initial two companies evaluated were Coca-Cola’s operations in El Salvador, and SAB Miller’s operation in Zambia.  Both companies are a major buyer of sugar in the respective countries, and it was the first time I began to understand how the demands of multi-national corporations affect operations of an industry like sugar in small local communities in developing nations.

Nicaraguan sunsets can be pretty spectacular.

Nicaraguan sunsets can be pretty spectacular.

Fast-forward three years.  In fall of 2012, I had just finished a post-graduate legal fellowship, but the organization I had been working for had taken a big financial hit during the Great Recession and couldn’t afford to keep me on payroll after the fellowship funding ran out.  As I settled into my post-employment job search, I realized this might be a good time to do another “co-op” to gain some additional job experience.  I figured anything would help in this ultra-competitive job market.

Opportunity presented itself in the form of La Isla Foundation (LIF), a small public-health focused NGO based out of León, Nicaragua.  LIF was founded in response to the alarming growth of an epidemic of Chronic Kidney Disease of unknown origin (CKDu) among western Nicaragua’s sugarcane workers.  Chronic Kidney Disease, also known as chronic renal disease or chronic renal failure, is a degenerative, progressive condition marked by the gradual loss of kidney function.  In developed countries, the causes of CKD are usually obesity, high blood pressure, and diabetes.  However, early research shows that these risk factors are not present in CKD patients in Western Nicaragua; here, the disease is of unknown origin (CKDu).  Because renal function declines at a gradual rate, death from chronic kidney failure is often slow and extremely painful.

Community members attending the funeral of a former sugarcane worker who suffered from CKDu.

Community members attending the funeral of a former sugarcane worker who suffered from CKDu.

According the Pan American Health Organization, the annual death toll from chronic kidney disease has more than doubled over the past ten years, from 466 in 2000 to 1,047 in 2010[1].  It is estimated that that since 2000, the disease has killed more than 24,000 people in Nicaragua and El Salvador alone[2]. However given the inconsistencies in reporting causes of death in the region, some believe that the toll is actually much higher.  In contrast to CKD in high income countries, CKDu in developing countries presents at a much earlier age.  In the communities where LIF works, men as young as 19 have been diagnosed with a disease and patients have succumbed to the illness as early as 21 years old.

Getting to know the sugarcane communities in western Nicaragua, I’ve been able to really see how the global value chain for sugar impacts rural communities in everyday life.  In the case of CKDu in Nicaragua, the workers’ place within the sugar value chains might literally be killing them, and few options for alternate employment exist.  I’ll admit, the issues are complex, and getting familiar with the details of the work can be depressing at time, but I love it.

And that’s coming a long way from not even knowing what a value chain was prior to my PHRGE co-op at Oxfam.

Purvi P. Patel, JD/MPH

PHRGE Fellow (fall 2009), NUSL ‘10


To find out more about La Isla Foundation and our work, go to, or like us on Facebook.  To contact me directly, write to

[1] See Pan American Health Organization, Distribution of Deaths by ICD–10 Chapters, available at (last visited Apr. 11, 2013) (comparing deaths in Nicaragua under Chapter XIV, Diseases of the genitourinary system for chronic renal failure, unspecified and end stage renal disease for2000 and 2010).

[2] Michael Weissenstein Associated Press, Mystery disease kills thousands in Central America (Feb. 9, 2012), Deseret News, available at–‐disease–‐kills–‐thousands–‐in–‐Central–‐America.html (last visited Apr. 11, 2013).

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