Chronic Renal Disease in Lower Lempa of Usulutan, El Salvador

In recent years, chronic renal disease (CRD) has become a serious public health concern throughout agricultural communities in Latin America.  The Lower Lempa region of Usulután, often referred to as El Salvador’s breadbasket, is no exception. Over the past ten years or more, farmers are diagnosed with CRD, a disease in which the kidneys fail to function adequately, at an rate of 30-45% of men above age 30. The number of cases has risen in recent years, and doctors and researchers are puzzled, as their patients are not traditional candidates for CRD.  Though similar epidemics of CRD are appearing worldwide, few in the public health field have undertaken in-depth or conclusive studies to determine its causes.  The World Health Organization (WHO) and Sri Lankan government recently began to investigate CRD in Sri Lanka, but they have yet to publish any findings.

Causes

These abnormal cases of CRD are most prevalent among male farmers, often young, who do not have the pre-existing illnesses, such as hypertension or diabetes, that are traditionally associated with the onset of CRD. In a 2001 study done in Jiquilisco, Usulutan, 71% of 132 men with CRD showed no signs of hypertension, diabetes, or other known risk factors, and suffered from the disease seemingly without cause. Studies conducted in Sri Lanka indicate that renal disease could be linked to any one of a number of factors, such as use of low quality aluminum utensils, cadmium ingested through food, fluoride in the ground water, and consumption of poor quality alcohol, but no decisive conclusion has been reached.

Many in the medical community believe that the most likely of these is the presence of cadmium in the environment. These farmers may be ingesting cadmium from any number of sources. It is used as an artificial phosphate in fertilizers and is also a byproduct of mining. If present in the soil or water, cadmium may be ingested by livestock and fish, or absorbed by crops, and then ingested by humans. Cadmium is also linked with other chronic and acute illnesses that include:

  • Diarrhea, stomach pains and vomitingDSC02014
  • Reproductive failure
  • Damage to the central nervous system
  • Damage to the immune system
  • Psychological disorders
  • Cancer development

CRD in the Lower Lempa

As mentioned, the 2001 Jiquilisco study found that 30-45% of men over age 30 in the municipality of Jiquilisco suffer from CRD. In 2005 the Fondo Social de Emergencia de Salud (Emergency Social Fund) reported that 23 people, in a population of about 40,000, died from renal failure, while the Salvadoran Ministry of Health reported only one death. Similarly situated communities in countries such as Sri Lanka and Nicaragua report as many as 200-300 deaths a year, indicating that the occurrences in Jiquilisco are likely to be under-reported.

Despite such high rates of CRD in the region, the local hospital and clinics rarely have the appropriate medications or dialysis machines necessary to treat patients.  The government-run clinic in La Canoa (a small community in the Lower Lempa of Jiquilisco), for example, rarely has the high-blood pressure medications used to treat CRD.  Even if the resources for detection and treatment were readily available, most patients are unable to afford them.  Though El Salvador’s Ministry of Health and other government agencies have neglected the problem, communities have begun to help themselves.  For the past few years, the Fondo Social de Emergencia de Salud has been educating people about the causes and prevention of renal disease. Their small size and few resources, however, limits their impact.

Patients diagnosed with CRD often require hemodialysis, but the government clinics and hospitals have so few machines that they are generally put on waiting lists. An alternative to hemodialysis, which must be done at a hospital or clinic, is peritoneal dialysis, a procedure in which the abdominal cavity is filled with dialysis fluid that removes toxins from the blood. Peritoneal dialysis can generally be done at home, but there is a shortage of supplies for patients, and most cannot afford the permanent abdominal catheter. In order to have the treatment, patients must go to a clinic twice a week to have their abdomen punctured for a temporary catheter.  The logistics of getting to the clinics, and having an abdominal catheter are significant for farmers in the Lower Lempa, and many stop treatment after a couple visits.

The public health and medical communities have yet to decide on recommendations for combating CRD among young, seemingly healthy farmers.  In Sri Lanka, the government is being proactive and testing all farmers for CRD.  In addition to more testing, government and non-profit health providers ought to take steps to prevent further cases, but because the cause of these CRD cases remains uncertain, its difficult to inform farmers how they may avoid contracting the disease. Ideally, communities ought to be testing and changing their sources of food and water, and using organic fertilizers. Already impoverished and marginalized, such steps are daunting for communities such as those in the Lower Lempa. Until the medical community is able to provide more complete prevention programs, the Ministry of Health ought to invest in the medications and machines necessary to provide adequate treatment.  In 2007 and 2008, Hospital Rosales in San Salvador opened two new wings to treat CRD patients, but they are hardly sufficient.

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