Facing a wall of towering sugar cane in charred shades of yellow, black, and brown, José Luis Rivas Masariego leans down to hack at a few stubborn stalks.
It’s barely 8 a.m. and already the heat is suffocating, his shirt soaked with sweat. Mr. Masariego tosses a few freshly cut shoots of cane onto a pile behind him when the sound of a plastic horn blares out across the fields.
It’s one of the many firsts that Masariego has experienced this cutting season.
For the past five decades, Masariego has swung his heavy machete from dawn to dusk. Breaks were rare: Cane-cutters are typically paid by how much they cut, and the geography of most fields provides no escape from the sun.
But this year, the horn heralds hourly breaks. Masariego, whose deep wrinkles and leathery skin testify to years working outdoors, can get a drink of clean water when he needs it, and take refuge from the sun under a blue tent. He and his colleagues sport hydration backpacks, moisture-wicking shirts, and lightweight machetes.
And for him and 11 others in this group of roughly 60, there’s one particularly visible change: thumb drive-sized motion sensors taped to their foreheads, arms, legs, and necks.
Tucked away in these rural fields in central El Salvador, a small revolution in the harvesting of sugar cane is under way. It’s an industry in which brutal work conditions have changed little in decades here, and workers have had few means to protect themselves. Indeed, an unusually high number of men in the prime of their lives have died across the region – many after toiling in sugar cane fields.
Over the past 20 years, more than 20,000 people in Central America have died of a kidney disease of undetermined origins, most of them cane workers.
While scientists and health organizations around the world work to identify the root causes, a handful of power brokers here – from a top businessman to government officials and community leaders – are starting to take action to reverse the trend, based on what they know. Masariego is part of the first scientific intervention among sugar cane workers aimed at determining if work-related conditions such as dehydration or heat stress play a part in chronic kidney disease (CKD). And the achingly simple changes being tested here could serve as a model for other employers and governments across Central America, helping to raise awareness of worker protection and human rights.
“We need to do more research to find the causes, but meanwhile we can’t wait around for that research to happen before trying different interventions,” says Michael McClean, an environmental health professor at Boston University who is part of a research team that’s investigated CKD in Nicaragua.
“Whether or not this pilot answers questions about [CKD], it’s a win-win situation for the workers. Conditions have to improve,” says Ramón García Trabanino, a kidney specialist in El Salvador who in 2002 published one of the first studies on CKD.
A mysterious rise
Walk into Rosales, El Salvador’s largest public hospital, and there’s a momentary sense of time travel. Nurses scurry about in white smocks and small rectangular hats; many of the buildings have century-old grand staircases and carved detailing.
It was here in the late 1990s that doctors began noting an influx in Salvadorans needing dialysis treatment.
“Patients were everywhere, even in the kitchens. The hospital was overwhelmed,” says Dr. Trabanino, who was completing his medical school fellowship at the time.
Patients’ backgrounds – including their relative youth – also caught doctors’ attention. Most were coming from the coast, and many worked in cotton or sugar production, says Dr. Ricardo Leiva, head of the nephrology department. “This was new territory.”
Between 2005 and 2012, hospitalizations for CKD in El Salvador jumped by 50 percent, making it the leading cause of hospitalization in the country, according to the Pan American Health Organization.
The demand for dialysis remains so pressing that Hilda Miranda de Lara, standing in a bustling waiting room one recent afternoon, recalls sleeping on the hospital’s concrete floor for five days with her husband before a spot in the treatment program opened up for him. About 50 new patients a month seek CKD treatment at Rosales alone.
But the government took little action for nearly a decade.
“There was a lack of political will,” says Carlos Manuel Orantes Navarro, a kidney specialist who heads investigations at El Salvador’s National Institute of Health (INS). And in some countries it went beyond that, with reports of researchers receiving death threats in Nicaragua after looking into links between the disease and sugar cane work.
But in early 2011, El Salvador’s then-minister of health caused a stir when she stood up at a United Nations conference in Mexico City and implored her Central American neighbors – and the world – to pay attention.
“[Dr. María Isabel] Rodríguez led the region. She got people to wake up,” says Trabanino, who is the principal local researcher on the water, rest, and shade intervention here. For the first time, the Ministry of Health began funding scientific investigations into CKD and identified the problem as a human rights issue.
Still, measured interventions have been few. That’s left local leaders to try steps ranging from refusing to turn more land over to sugar cane production to driving sick citizens to hospitals in the capital to calling for restrictions on the use of agrochemicals.
In 2013, national politicians proposed banning 53 agrochemicals in El Salvador, fearing they could be to blame for the rise in CKD.
But work that focuses on actually changing the habits that scientists suspect could be related to the disease – a key factor in fostering progress – has been thin, says Dr. Leiva at Rosales Hospital.
“We’re talking about the risk factors, but we aren’t giving [people] alternatives so that they can try to avoid those factors,” he says. Scientists are eyeing a range of issues, including dehydration, the overuse of pain medicine, chemical exposure, or residual effects of mosquito-borne diseases.
A very hard day’s work
Dawn is just breaking as a white-painted school bus pulls off a dirt road into a sweeping field of sugar cane.
A ragtag team of men and one woman pile out wearing flip-flops, sandals, and flimsy tennis shoes. Many carry water in plastic jugs like those used to hold detergents or cleaning supplies.
El Salvador is considered a lower-middle-income country, but you don’t have to look hard to spot the roughly 35 percent of Salvadorans living in poverty. The economy is bolstered by remittances, which make up roughly 20 percent of the country’s gross domestic product – and contribute to a lack of local industry and employment opportunities. Access to health care and sanitation is imbalanced, and roughly 1.5 million people lack clean water, according to Oxfam.
People with CKD in El Salvador really “die of poverty,” Leiva says.
Lifting up his shirt to mop sweat from his face, José Rene Bonilla, who has been cutting sugar cane for five years, says he’s pleased with the intervention and hopes it will continue. He’s less dizzy at the end of the day, and he says most of the time he’s cutting more cane than in the past, even with the added breaks. But he’d consider other employment if it were an option.
“As a father, I want my kids doing something else,” says Mr. Bonilla, one of whose four children is in charge of blowing the neon green horn every hour alerting workers that it’s break time.
“You lose your life doing this work, and you gain nothing,” he says. Most cane-cutters here are working to make enough money to plant corn, beans, and other food for their families’ consumption in the off-season. They report daily salaries between $5 and $15. It can add up to more than double the minimum wage of $114 a month – but the cutting season only lasts six months.
Like running a half-marathon – daily
As the day progresses, the fields take on an almost apocalyptic feel: The formerly towering sugar cane has been systematically cut, lifted, and thrown behind each worker into a trail of flattened stalks.
The work is repetitive and takes a toll. Imagine running a half-marathon in 100-degree F. heat five or six days a week for six months. That’s about equivalent to the amount of energy a Salvadoran cane-cutter expends in each day’s work, says Robert Quirk, a consultant on the intervention and a board member of the Australian Cane Farmers Association and Bonsucro, an international nongovernmental organization that promotes sustainable sugar cane.
The Ministry of Labor and Social Welfare claims that all places of employment – including sugar cane fields – are inspected, a result of a 2010 workplace safety law. But change has been slow to come.
“There isn’t a culture of safety or the expectation for safety in the workplace in El Salvador,” says Ronoel Vela Cea, subdirector general of social prevention at the Ministry of Labor.
About 30 minutes north of the capital, San Salvador, a handful of idling 18-wheelers brimming with sugar cane stalks line up in front of a weigh station at Ingenio El Ángel. The sugar mill’s president, Juan Wright, sits nearby in an air-conditioned conference room that feels worlds away from the cane fields.
His company is covering the workplace expenses, about $170,000, for the intervention, which involves two cutting teams out of roughly 24 groups working for El Ángel. If cutting sugar cane “can be improved in the name of health and human rights, you have to do it,” Mr. Wright says of his motivation to team up this year with the US-based NGO La Isla Foundation and Netherlands-based NGO Solidaridad. The NGOs are administering and covering the expenses for the scientific work, which also includes taking soil samples and studying the ergonomics of body movement patterns as workers cut over the course of the season.
“If we demonstrate you can do something, and there’s evidence to back it up, it’s more likely to become mandatory to comply with those standards,” Wright says.
Julio César Arroyo, the executive director of El Salvador’s sugar association, says the group will “definitely” implement standards from the intervention if the study proves to make a difference. Already most of the country’s six mills are supplying water to their workers, and the group’s sustainability arm, FUNDAZUCAR, recently published a guide on best practices for sugar cane landowners. About 80 percent of sugar cane here comes from land that’s not owned by the mills, which means mill owners don’t have direct control over those working conditions.
“I think the positive side of all this is that we hopefully will now have a model that works,” says Mr. Quirk. “If this can then become the norm rather than the exception, then we can save a lot of lives,” he says, adding that it “behooves the world, especially buyers,” to invest in programs like this.
‘Who is listening to us?’
A preliminary scientific analysis of the intervention is expected in mid-June, and already the INS has expressed interest in bringing the program to a sugar cooperative next year.
Back in the fields of El Caulote, a symphony of metal scratching on metal breaks out as workers sharpen their machetes after lunch. José Rivas pauses to knot a dark bandanna around his neck and explains that his brother used to work in the fields with him, but has been in the hospital now for months. “The sun bothers us, and we need our rest,” Mr. Rivas says. “We have the right to share our opinion in this country. The problem is, who is listening to us?”