The Silent Epidemic Behind Nicaragua's Rum

"This is so amazing!" I quip as I am being driven into the heart of the rum factory. It's a gorgeous campus of manicured grass and palm trees. Distillery tanks are painted a pearly sheen of white, and hundreds of oak barrels imported from the United States are neatly stacked on top of each other. Each distillery tank contains one million liters of alcohol; there are 18 of them on the campus. From the corner of my eye, I see a group of thin, gaunt workers dressed in dirty protective gear pass by, standing on the back of a large truck—their eyes icy and unemotional.

I'm inside the Flor de Caña rum factory in Chichigalpa, a small town in western Nicaragua, playing the part of an enthusiastic tourist with an extreme knack for questions. With me is a genuinely thrilled family of four visiting from Mexico.

Flor de Caña is Nicaragua's best-known export, and it has an impressive stash of slow-aged barreled rum—one of the largest in the world. You can find the liquor at virtually every bar in Nicaragua and it's exported to over 40 countries. My tour guide tells me that the number-one market is Chile, followed by Canada, the United States, and then Nicaragua. The rum is good, and the company has a diverse portfolio. The liquor is smooth, slightly dry, and the aged varieties have hints of vanilla and oak.

Flor de Caña is operated by Nicaragua Sugar Estates Limited (NSEL), a subsidiary of Grupo Pellas. Grupo Pellas controls more than 20 companies in the country and boasts $1.5 billion in annual sales, equal to 13 percent of the country's gross domestic product. Carlos Pellas, the major shareholder in the company and a close friend of Nicaraguan President Daniel Ortega, is Nicaraguan's first billionaire. His nickname is "the sugar king."

Many citizens of Chichigalpa are employed by Flor de Caña and its sugarcane mill, Ingenio San Antonio (ISA). Sugar is Central America's largest agriculture industry and makes up about 4 percent of the nation's GDP. ISA produces more than 63 percent of the country's sugar, equaling almost 17,000 metric tons per day. It also provides Flor de Caña with all the molasses for its rum.

At the rum factory, the Pellas family is naturally regarded with high esteem. There's an entire exhibit dedicated to their legacy.

I'm shuttled to an old theatre where I watch a video presentation chock-full of facts and statistics that praise the Pellas family and its efforts to benefit the community and sustainability. Chichigalpa is a monoculture town, built entirely on the sugarcane industry and intertwined with ISA and Flor de Caña.

I learn that the company has planted 50,000 trees. In the spirit of social responsibility, it has set up schools and a food aid program in Chichigalpa. Its hospitals have facilitated 2,929 births and 9,036 surgeries. It even provided the city with shiny new parks.

The family I'm with on the tour nods with enthusiasm after the video ends, and the five of us pile back on the tram to a private tasting room.

Three miles past the glistening rum factory, down the main street and into the core of the city, the landscape couldn't be more different from the trimmed, green factory grounds. I spend a morning at a community center. Volunteers are preparing lunch when they realize there is no water. A local tells me that the water and electricity are unreliable, and by 9 PM, the water is shut down.

But it's more than just shoddy utilities that set this town apart: Chichigalpa's citizens are dying at an alarming rate.

"A couple years back, an old cemetery guard kept a book of names and how they died," Julie Rhonda,* a La Isla Foundation field researcher, tells me. La Isla Foundation is a human rights and public health NGO that has done extensive studies on Chichigalpa and ISA. "When I looked at it, I saw 'CKD,' 'CKD,' 'old age,' 'CKD,' 'CKD,' 'CKD.'"

CKD stands for chronic kidney disease of untraditional causes. In Chichigalpa, the rate is more than six times the national average; at least 2,800 to 3,500 people have died from the disease in the last decade. It's a disease that researchers have linked to working conditions at the sugarcane mill.

"The decline in kidney function during the harvest and the differences [in kidney function] by job category and employment duration provide evidence that one or more risk factors of CKD are occupational," a 2015 Boston University study concluded. The study followed 500 sugarcane workers in Chichigalpa and found that the kidney function of field workers declined over the course of the six-month harvest. Sugarcane cutters and planters saw the sharpest drop.

Chichigalpa is a ghost town—it sees three to four deaths a day in a city of roughly 60,000. The depression is tangible; I sense it in just a few minutes on the ground. When I ask locals how they're doing, they respond with "in crisis" or "trying to get through life." Death lingers at every corner and funerals are regular affairs. Coffins are in such high demand that the local government subsidizes them. Six years ago, a new cemetery was built to accommodate the dead. Today, it's almost 20 percent full.

I meet Julio Lopez,* a 33-year old former sugarcane worker who spent 12 years with ISA and Flor de Caña. We speak outside, sitting on the sidewalk. Whenever a police officer or a potential government official walks by, Lopez stops talking immediately. He tells me that even at the wakes of CKD victims, government officials will sometimes stop by to intimidate. Paranoia runs deep in the city because the government and the company are so intertwined.

"I started at the factory when I was 18 years old," Lopez says. "I was cutting burnt cane and worked in ethanol production. We were exposed to harsh chemicals but supposedly we had protective gear."

Lopez contracted CKD at the age of 29 while working on the sugarcane field and has been on his deathbed multiple times.

"Your body is burning up, you feel suffocated," he says. "You're lying there and you think it's going to be the last day of your life and then you get it under control—living with a high level of creatinine. Another heat stroke and you could go. You leave the clinic, you look at the sky, you look at your family and kids and decide that you need to take care of yourself."

These days, he drives a tricycle taxi and limits his workdays to maintain his health. He talks fondly about his children, two boys, ages four and nine. There is free healthcare in Nicaragua to an extent, and ISA has provided their workers with health consultations since 1951, but Lopez claims that once workers' creatinine levels rise above normal, they are immediately let go. And because most of them are seasonal workers, they aren't eligible for benefits. Further, subcontracted workers like Lopez do not have access to the mill's hospital or services.

"Workers are paid per the ton of cane they cut," Lieneke Wieringa, advocacy manager for Fairfood International says. "This invites workers to work long days and weeks with little or no breaks to earn somewhat of a decent income. Especially taking into account that many of the workers are only hired during the harvest season. With very limited other jobs available they need to earn their living for an entire year in just six months' time."

Because of this financial desperation, many use fake IDs, go back to cutting sugarcane, and get even sicker. Lopez says that it's an open secret that many supervisors let slide by.

The CKD epidemic isn't new or even specific to Nicaragua. It's been tracked in sugarcane fields in Costa Rica since the 1970s, and according to data from the Pan American Health Organization, Nicaragua and El Salvador have had the highest rates of CKD in the Americas in the last decade.

But Chichigalpa is especially vulnerable. The municipality and its surrounding communities experience some of the highest rates of CKD in the country. From 2002 to 2012, the disease caused 46 percent of all male deaths and 75 percent of the deaths of men aged 35 to 55.

"Please help us," Dr. Ramon Garcia Trabanino says. Trabanino is the president of the Association of Nephrology of El Salvador, and has treated countless numbers of CKD patients. He was one of the first people to publish a study on CKD, in 2002 when he noticed large numbers of men between the ages 20 to 40 being admitted to his hospital with advanced cases of the disease. "We've been studying this for 15 years we've been screaming to this world that we have this epidemic," he says. "We have this silent massacre going on here."

Conditions in sugarcane fields are harsh: Without access to water and shade, workers lose approximately 2.4 kilograms of weight in one working day. During the harvest season, some respondents to a survey conducted by the La Isla Foundation worked 12 hours a day in temperatures that climbed past 100 degrees Fahrenheit. Sugarcane cutters are paid less than a dollar per ton of cane harvested; they harvest an average of four to eight tons. According to Fairfood International, as of September 2013, the agrarian minimum wage is far below the value of the basic basket of goods and services calculated by the Nicaraguan Institute of Development Information.

"One could say that one day of sugarcane cutting can be compared to running half a marathon, in terms of physical efforts," Wieringa says. "Imagine doing that six to seven days a week, six months in a row without proper rest and hydration."

Many workers have attributed CKD to pesticide exposure in the fields, but researchers who have been working on this issue for years maintain that the solution is much simpler than swapping out pesticides—though not necessarily easier to implement.

"It's rest, water, and shade," Trabanino says. "Those are the recommendations we make for all of our kidney patients. You have to rest under shade for at least ten or 15 minutes out of each hour. And then you have to drink enough water. The problem is that every year it's getting hotter and hotter, and so there are days when even drinking water is not enough."

In El Salvador, Trabanino is part of a program called the Worker Health and Efficiency Program at sugarcane mill Ingenio El Angel in El Salvador. It tracked 65 people during the last harvest—giving them rest, water and shade, a more ergonomic and effective machete, and improved strategies for cutting the cane. Hydration backpack manufacturer CamelBak provided steeply discounted backpacks to the mill, which provided them to workers at no cost, ensuring easy and constant access to water.

"It's early, but after the rollout of the intervention, kidney functions stabilized, and heatstroke among workers was eliminated," Jason Glaser, founder of La Isla Foundation and the Worker Health and Efficiency Program says. "This year we are increasing the numbers of participants to make sure our results have greater statistical significance." He notes that the program actually improved efficiency in workers by 40 percent compared to what they cut the year before.

I ask Glaser why they can't do this in Nicaragua and why ISA has been so against improving conditions.

"They want to do what's best and what's best is within their pragmatic interest, which is not to have lawsuits," he says. "And in San Antonio, they're in a totally closed loop. They're the largest family in the poorest country in Central America and they're accountable to absolutely no one. They have no international exposure except for Flor de Caña. The other problem is that the Nicaraguan government is getting all their information on that issue from the Pellas group."

He pauses. "I'll give Carlos Pellas this one break, though: I don't think he knows really what's going on," he says. "He runs a multibillion dollar empire. He's not on the ground or knows what's going on at that mill. I think he relies on his people there."

The situation is so severe that people in Chichagalpa have begun to demand that their town be declared an emergency zone. Last year, men and women affected by the disease marched 80 miles to the capital of Nicaragua to make their case. The trek took them 11 days. When they arrived, no one from the government met them.

For its part, ISA has denied wrongdoing and maintains that it has implemented hydration, rest, and shade policies. "Field workers, such as cane cutters, receive adequate hydration for the labor they perform in the form of water and hydrating solutions certified by the Ministry of Health, a balanced lunch prepared by a specialized company, food aid for their families, and medical care at Ingenio San Antonio's Hospital," Ariel Granera Sacasa, the direction of communications for Groupo Pellas says.

"This is for a very small percentage of contracted workers," Glaser tells me.

I ask La Isla's field researcher, Rhonda, for her take. "I've been to a variety of fields, some under supervision of Nicaragua Sugar Estates Limited and a couple more where I came uninvited and unexpected," she says. "On the tour, they made an attempt at shade, water, rest. On the fields where I showed up without notice, there was no trace of water or shade to be found, and there certainly were not workers resting at any point."

Sacasa points out that there is a mobile clinic equipped with a cooling area that takes blood and urine samples, and offers hydrating beverages and food. He also claims that workers are paid for the seventh day of rest.

"We are told that our pay includes the seventh day, but that is not true," Joe,* who works in the human resources department at ISA says. Joe has been working for the company for five years and notes that during his first year, when he was cutting sugarcane, his creatinine levels went above normal. He has since been able to control them.

"The company believes that they are providing us with the right provisions, but they are not doing it the right way," he says. Part of Joe's job is to distribute rehydration packets and medicine supplies to workers. "A lot of times we are working and there are 200 men to give out supplies to, and there is just not enough."

Joe also claims that the mobile clinics only screen workers that are not sick, and that whenever there are visitors to the fields, more provisions are given.

"When the CAO [Compliance Advisor Ombudsman of the World Bank] came to visit, [the company] brought out more tents," he says. "There's usually just one tent per bus. But when they came, they brought in an entire pickup truck full of tents."

Joe admits that, in recent years, improvements have been made in terms of working conditions. "Before we worked 14 days straight. Now we work six days straight," he says. It is true that they get rehydration packets and food is provided. However, the changes are not enough, he says.

Not all employees of Grupo Pellas and its companies are so openly critical. In fact, my tour guide at Flor De Caña waxes poetic about the benefits of working there. He tells me that at the end of the year, employees of the Flor de Caña factory get free rum and sugarcane field workers get up to 60 pounds of sugar. If employees are let go, the company provides them with a hefty compensation package.

"It's better than any other company," he says.

Edward Hamilton, a rum consultant who has visited over 50 distilleries around the world, says that though he is aware of the human rights allegations surrounding it, Flor de Caña is among some of the better liquor companies. "It's a very forward-thinking operation," he says. "The sugar mill hires contractors and contractors hire people out in the fields. The contractors weren't taking care of the people that they should have or giving them the right protective gear. It's basically a Third World mess."

"That's a classic cop-out," Glaser argues. "The company makes money off the labor provided by the contractors and saves money by pretending they don't have a responsibility to the workers due to a dubious legal agreement supposedly insulating them from liability via contracting. The fact is, the workers contracted cut cane for ISA, and ISA should ensure their supply chain is free from abusive work practices. They own or rent directly nearly all the land they claim cane from and manage these contractors and their tasks directly in order to remain efficient."

Sacasa denies these claims. "Ingenio San Antonio maintains a rigorous supervision to ensure that contractors comply with the laws of the country and all the hygiene and occupational safety rules that are applied in the company," he says.

He adds: "In terms of the impact of CKD in the workforce at Ingenio San Antonio, we believe it is appropriate to point out that from 1996 to date, more than 140,000 people have worked there. Of these, only 1.82 percent has been affected by kidney problems."

"The company is good for Nicaragua," says Nicaraguan native Fatima Quant, who helps to arrange tours at the Flor de Caña factory. "They invest, they create companies. Other companies take the resources and leave. But here, the money stays. In Chichigalpa they have schools for free, houses for free, [and people] live there for free. It's not so bad."

But when I visit the community of La Isla, just on the outskirts of town in Chichigalpa, the scenes I see couldn't be anymore different. The town is severely impoverished. Roofs are made out of tin and houses are scattered throughout thick vegetation. At La Isla, the death rate is even more extreme: more than 70 percent of male deaths are due to CKD. There are at least 78 widows for 400 families and the rate is so high that they've nicknamed themselves "The Isle of Widows."

I speak to one of the widows, whose husband, a sugarcane employee, died seven years ago. He was 32. Like everyone I talk to in the town, she asks to remain anonymous in fears of government repercussions. She has four children and sells fruit to survive. I'm in front of her house—a worn-down shack surrounded by overgrown trees. Her four small children sit inside, staring out at me.

"We are struggling," she tells me. "It's been very difficult without him."

I ask her if she's angry. Her community is made of up women like her—young and widowed, left with a handful of mouths to feed.

She pauses. "This is just our reality," she says.

"The jig is up and it's time to start addressing the issue," Glaser says, "Our job isn't to end ISA or end the Pellas Group, and they kind of always acted that was the objective. Our objective is to create a viable environment for human beings."

Back at the rum factory, around the perimeter of the beautiful campus, security is tough. I've actually taken a genuine liking to the security guards and my tour guide. They answer my questions with patience, and they wave and smile at tourists with goodwill. It's hard to imagine that just a week prior to my visit in mid-October, there was a protest outside of the factory by former sugarcane workers. Fifteen people were charged and some folks were jailed. Nearly a month later, they're still imprisoned. Many of them suffer from CKD.

In Nicaragua, there's a paranoia that extends to everyone I talk to regarding this issue. Glaser himself was denied access to the country in February. Former sugarcane workers and citizens are upset, but don't want their names to be published.

"The reason why the crackdowns are so hard is that the narrative police are getting is that these people are sick because they just drink too much and that they're just greedy. Even the government is insulated from the truth," Glaser says.

"Right now we have a government in this country that is completely corrupt and it's in bed with the private industry," Joe says, noting that the harvest season begins today. "I've seen people that have been paid off by the company to not talk. Every week there are workers leaving because of chronic kidney disease."

At the end of my tour, I ask my guide about visiting the fields.

"You can't go there," he tells me. "There are a lot of guards."

"Why?" I ask innocently. "It's such a shame. I want to see how sugarcane grows."

"Because people in the past have stolen sugar," he said.

Glaser laughs when I tell him this story.

"I mean, sure, some people do steal sugar, but that's not why the guards are there," he says.

The truth isn't so far away. Just meters away from those precious fields are the graves of those who have died. What's noticeable is that so many of the graves of men who have died of the disease are unmarked with no names. There are only dirt piles over their cheap, wooden coffins. It is as if the people are tired of marking their dead.

It's a deadly price to pay for rum, or as the locals call it, sangre de cañero.

Blood of the sugarcane workers.

*Names have been changed t0 protect sources' identities.