Challenges

Chronic kidney disease of non-traditional origin (CKDnT) in Central America, also known as Mesoamerican nephropathy, is a clinical and epidemiological phenomenon that especially affects agricultural communities and that has been linked to specific crops, such as sugar cane, as well as to subsistence agriculture. In Costa Rica and Guatemala, CKDnT has been detected in workers in other economic areas, such as construction. CKDnT has been found in populations that migrate between or within countries to perform seasonal work—populations that tend to be particularly neglected and that lack access to health care (Wesseling, et al., 2020[1]). The disease has been recognized as a serious public health problem, and a priority issue, associated with occupational risks, especially heat stress.

A survey of social actors on the current CKDnT situation in Central American countries and the Dominican Republic, conducted with the support of the Pan American Health Organization/World Health Organization (PAHO/WHO) in 2021, identified the male population, and men between the ages of 20 and 55 in particular, as most affected. Agricultural workers (working with sugar cane, and in Costa Rica also with rice, melon and oranges), migrants, contingent workers and construction workers are most affected [2] and lack access to health systems and social security as a result of their working conditions.

[1] Wesseling, C., Glaser, J., Rodríguez-Guzmán, J., Weiss, I., Lucas, R., Peraza, S., da Silva, A.S., Hansson, E., Johnson, R.J., Hogstedt, C., Wegman, D.H., Jakobsson, K. “Chronic kidney disease of non-traditional origin in Mesoamerica: a disease primarily driven by occupational heat stress.” Rev Panam Salud Publica. 2020 January 27;44:e15. doi: 10.26633/RPSP.2020.15. PMID: 31998376; PMCID: PMC6984407.

[2] Survey of Social Actors on the Current CKDnT Situation in the Central American Countries and the Dominican Re PAHO 2021, pending publication.

Toward a Solution

To address this challenge, since 2018, at the initiative of the integration bodies of the Central American countries, and with support from PAHO/WHO technical cooperation through the Central American Subregional Program (CAM), a series of steps have been promoted to define a strategy based on scientific evidence for the Central America region and Dominican Republic to tackle the CKDnT epidemic.

The Technical Commission on Chronic Diseases and Cancer (CTCC), guided by the Secretariat of the Council of Ministers of Health of Central America (SE-COMISCA) and formed by the eight Central America Integration System (SICA) countries (Belize, Costa Rica, Dominican Republic, El Salvador, Guatemala, Honduras, Nicaragua and Panama) with technical cooperation from PAHO/WHO through the CAM Subregional Program, has been meeting weekly or bimonthly over five years to share information on good practices, success stories and progress from different countries. 

A group of multidisciplinary experts were organized (the ad-hoc group of CKDnT), who serve as focal points for the eight SICA countries to share and exchange information on each countries’ challenges, solutions and progress, while taking care to recognize specific and unique factors at play in individual countries and the varying levels they have reached in addressing CKDnT. A situation analysis of CKDnT in the subregion was carried out with the support of PAHO/WHO. Scientific evidence was exchanged to build nine streams for the strategy and their objectives, activities, goals and indicators.

The first draft of the Strategy for Chronic Kidney Disease of Non-Traditional Origin in Central America and the Dominican Republic was finalized in May 2022 and approved by COMISCA in June 2022.

In addition to a finalized strategy, the exchanges among SICA countries achieved the below results.

1. Clinical and epidemiological case definitions for CKDnT in the Central American subregion.
2. Progress on strengthening epidemiological surveillance systems to improve the recording of mortality, prevalence and case monitoring.
3. Signature of COMISCA Resolution 27–2018, spotlighting the issue of kidney disease in the SICA subregion to define actions for preventing this disease.
4. A public health situation analysis of CKDnT in Central America and the Dominican Republic, including follow-up actions, was produced in 2021 with the support of PAHO/WHO focusing on surveillance of CKDnT, prevention policies and strategies for the promotion of kidney health, knowledge about access to health services, including alternative treatments and transplants, and review of the regulatory framework in relation to the health of populations at risk and social protection of patients with CKDnT.
5. Agreement among the SICA countries to promote the health of workers in agriculture and other occupations who endure long working hours with high exposure to heat, lack of opportunity to rest in the shade and lack of access to adequate hydration, by seeking programmes to improve their working conditions.
6. Some countries made notable advances for target populations. For example, in Costa Rica technical work and intersectoral and inter-institutional advocacy led to approval of a decree that regulates the working conditions of agricultural populations and incorporates mandatory compliance with regulations on shade, rest and water (Decree No. 39.147-S-MTSS) and hydration standards (Decree No. 39589-S), which support these preventive actions in the workplace. This achievement is the result of research and work on CKDnT with CTCC.

This experience can be replicated in other regions where climate and working conditions similarly affect workers’ health. To ensure sustainability of the initiative, political commitment is needed along with robust and defined teamwork that includes multidisciplinary actors from across countries of a subregion, supported by leadership of government health officials at ministerial level, SE-COMISA, along with strong technical support of PAHO/WHO.