News of the CKDnt epidemic – and PREP

Key words: CKDnt; La Isla Network; San Antonio Sugar Mill; work practices.

Despite early friction between the La Isla Foundation and the San Antonio Sugar Mill in Chichigalpa, Nicaragua, in 2019 an initiative called Adelante was funded by two German organisations. The initiative helped the foundation and the mill to cooperate in research to validate and adapt new work practices which would help sugar cane workers avoid or reduce the risk of contracting CKDnt (chronic kidney disease of non-traditional sources) as a result of their work in searing temperatures, with little shade and insufficient water.

The Adelante Initiative is a workplace intervention focused on providing adequate measures such as water, rest, shade, and improved ergonomics to prevent CKDnt among sugarcane workers. The La Isla Network (LIN), which sprang out of the La Isla Foundation, is concentrating its efforts in the sugarcane sector due to the high prevalence of the disease. The results from the initiative will be adapted to other geographies and industries.

The San Antonio Sugar Mill and LIN continue to invest their own resources into the project and additional support is provided by other project partners who are critical to the success of Adelante. The Nicaragua Sugar Producers Association ensure the project grows both within Nicaragua and the region. Bonsucro ensures the findings are disseminated internationally and the findings are being incorporated into an improved Bonsucro Standard.

Most recently the LIN has become a recipient of a Belmont Forum grant for the project ‘Prevention Resilience Efficiency and Protection’ (PREP) for workers in industrial agriculture in a changing climate. The Belmont Forum is a partnership of funding organisations, international science councils, and regional consortia committed to the advancement of science.

PREP will use the results of the Adelante Initiative to investigate:

  1. the immediate and long-term impact the intervention has on workforce health (kidney health and heat-related injuries) and productivity;
  2. the economic and social impacts on those affected by the disease and whether LIN’s intervention aids resilience, which includes mitigating migration pressures;
  3. the economic burden on health systems treating CKDnt;
  4. an analysis of public health policies to understand what specific policies, or absence of them, have contributed to CKDnt, while investigating what policies are required to effectively address the disease.

The PREP Project aims to strengthen protections for worker’s health by building on the Adelante Initiative.

The lay summary of LIN’s most recent publication is available at:[UNIQID]

For more information on PREP, please visit:[UNIQID]

Other LIN, CKDnt and PREP videos:[UNIQID][UNIQID

LIN website:

New film shows toll of heat stress on workers, plus world-leading protections developed in Nicaragua

Positive news among so much violence and distortion of the meaning of ‘development’ comes from La Isla Network whose research aims to counter the effects of extreme heat stress from work in the sugar cane fields. Initially prompted by the epidemic of Chronic Kidney Disease of non-traditional sources (CKDnt) around the Ingenio San Antonio in Chichigalpa in Nicaragua, the Ingenio (sugar cane processing plant) and LIN were initially very much at odds with each other’s work; but they are now partners in research and in attempts to improve the working conditions of the sugar cane plantation workers.

Below LIN recounts details of the problems encountered in the sugar cane fields and tells of the research behind their videos and interventions. Their videos can be found at:

October 20th, 2023

The latest film from La Isla Network with Talking Eyes Media, funded by the EU ENBEL project, demonstrates how worker protection protocols from extreme heat are saving workers’ lives. Once at odds, now La Isla Network and Ingenio San Antonio in Nicaragua — with a cohort of leading researchers on heat stress — are leading the world in modelling how to protect workers from exposure to extreme heat.

When workers are confronted with a heavy workload, exposure to heat, and poor labour protections, their risk for heat-driven illness, injury, and death increase. Though the body attempts to cool down, factors like ambient heat and the demands of the job mean workers’ bodies cannot cool down properly, note researchers Vidhya Venugopal and Andreas Flouris.

Mr. Flouris is an environmental physiologist studying how heat affects living organisms. He holds teaching positions at the University of Thessaly in Greece and the University of Ottawa, Canada. “There is an urgent need to address exposure to heat at work now, as our climate is changing faster than we had previously anticipated, while there are parts of the world — such as Europe — that are heating up much faster than the global average,” he says. “With heat waves increasing in severity, duration, and frequency in all parts of the world, exposure to heat at work is an issue of utmost urgency to address.”

In Nicaragua, by the time the sun has risen, sugarcane cutters at Ingenio San Antonio have begun work. They prepare for the workday. One of them carries a tarp that will serve as the shade tent: light and portable, yet highly effective.

Kristina Jakobsson is a medical doctor and researcher at the University of Gothenburg. She is also a member of the La Isla Network Scientific Advisory Board. For 20 years she has collaborated with colleagues the world over to understand the drivers behind chronic kidney disease of non-traditional causes among industrial agricultural workers.

After years of studies, researchers have found heat stress to be a driver of ill health. “Low-tech workplace interventions with regulated rest in shade, and access to water can protect workers,” she says. “This is old knowledge — nothing new, no rocket science — but our hope is that the combination of scientific evaluation, practical tools for workplace interventions, and a wider awareness of how heat affects work may lead to protection of the most vulnerable workforces.”

Since 2017, that has been possible in Central America, through the Adelante Initiative and the Prevention, Resilience, Efficiency, and Protection (PREP) Programme. They are La Isla Network’s marquee worker protection programmes, being implemented in the world-renowned Ingenio San Antonio, known for producing the sugarcane needed for Flor de Caña Rum.

Dr. Denis Chavarría, Occupational Health Manager at Ingenio San Antonio, notes excitement at the mill’s continued partnership with La Isla network and Bonsucro, the global sustainability platform for sugarcane. He says, “As founding members of the Adelante Initiative, Ingenio San Antonio has helped develop pioneering programmes that have significantly improved worker safety and reduced heat-related risks, but most importantly, we are developing the highest standards in occupational safety and health that will have a profound impact globally not only in our industry, but also across other labour-intensive industries.”

The results from Adelante and PREP have been nothing short of remarkable: a 72% reduction in injuries, a 94% reduction in worker hospitalizations due to heat stress, a 20% increase in productivity and a return on investment of 22%. Further, we demonstrated that preventative measures were over 1,600% more affordable than treatment, providing relief for overstretched healthcare systems.

With results in hand, La Isla Network and its partners now seek to implement the model elsewhere, especially in the United States and Europe.

Jason Glaser, CEO and co-founder of La Isla Network, asks, “Why is it that in Ingenio San Antonio, in Nicaragua, there are better work protections for those field workers than any farm in the United States of America that’s facing similar heat stress?” Now, La Isla Network is making it its objective to bring home what the organisation has done abroad to the United States and Europe. At the same time, now that data is in-hand, the organisation and its partners are pushing for legislation to better protect workers.

La Isla Network and its partners are making good progress. Recently, the team sat before the United Nations Human Rights Committee to bring awareness to exposure to heat at work, for example. La Isla Network will continue the effort hand-in-hand with its partners.

An essential aspect of that objective is to communicate not only the extent of the problem, but also the solutions being implemented, in a visual manner. This film was produced with Talking Eyes Media, a nonprofit production organisation engaging the world in today’s most pressing issues with unmatched documentaries. The organisation began in 2002 when writer, filmmaker Julie Winokur and photojournalist Ed Kashi teamed up. Both bring decades of experience, and world renown, to the table.

Ed Kashi says, “My goal is to continue to raise awareness about exposure to heat at work and CKDnt, but also to create changes, so as to protect workers and disseminate vital stories and information through my storytelling work.” He has worked with La Isla Network for 10 years now.

Julie Winokur says, “Collaborating with La Isla to tell this story gives me hope. Visiting Nicaragua for this film was an opportunity to witness a successful intervention put into practice in one of the most challenging work environments imaginable.

“This film illustrates the level of scientific research and employer commitment needed to ensure worker safety and productivity despite a warming planet.”

The film was funded by the ENBEL project, the EU-funded research project connecting health and climate change. Kristin Aunan, research director at CICERO Centre for International Climate Research and coordinator of the ENBEL project, says, “Workers’ health in the face of climate change is often overlooked despite causing great human suffering and economic consequences in many places in the world. We hope this film and the work showcased in it will contribute to get this important topic higher on the agenda.”

La Isla Network would like to thank: Dr. Vidhya Venugopal, Dr. Andreas Flouris, Dr. Kristina Jakobsson, Dr. Rebeka Lucas, Denis Chavarría, Ed Kashi, Julie Winokur, Tom Laffay, Miriam Stackpole Dahl, and Kristin Aunan.

Sugar cane production and the CKDnT epidemic

In May 2016, ENCA members Esma Helvacioglu and Martin Mowforth, spent a day as guests of the organisation PASE (Profesionales para la Auditoria Social y Empresarial / Professionals for Social and Business Auditing), a non-profit organisation formed in 2003 that is dedicated to the promotion of labour and human rights in the agricultural and textile industries of Nicaragua. Their work has alerted many people to the epidemic of chronic kidney disease suffered particularly by workers in the sugar cane fields. The following report uses much of PASE’s education and awareness-raising material along with various impressions gained by Esma and Martin during their visit.

As we sip our tea, coffee, lemonade, juices and numerous other sugary drinks, it is quite possible that most of us have no idea that there is a global epidemic of chronic kidney disease of non-traditional causes (CKDnT) amongst sugar cane workers around the world. In particular this is affecting cane workers in the Indian sub-continent and in Central America, especially El Salvador and Nicaragua. Sugar, one of Nicaragua’s most lucrative crops, feeds our insatiable sweet tooth. It is harvested by workers who labour under intense heat for poverty-level wages. They are also dying in epidemic numbers.

Researchers have linked poor labour conditions to the epidemic of Chronic Kidney Disease of non-traditional causes (CKDnT) sweeping across Central America. One of the populations most acutely affected by the epidemic is sugar cane cutters in western Nicaragua, although the same disease is noted in plantation workers in the Indian sub-continent and in El Salvador.

The lack of treatment options and resulting medical complications mean that a CKDnT diagnosis in Nicaragua is likely to lead to a slow and painful death. In the past ten years, 46% of male deaths in Chichigalpa, the most affected town, were caused by CKDnT. The epidemic devastates not only the lives of the sugar cane workers, but also the well-being of their families and entire communities.


Social security can mean life or death for a family

When cane cutters become sick, they are fired from their jobs and illegally denied social security benefits and compensation for their occupational illness, leaving their families with no income and forcing their children out of school and into labour. Nicaragua has few dialysis machines available for treatment and, despite its laws regarding labour conditions of work, there is precious little enforcement of these laws. Obtaining social security benefits in the poverty stricken rural sugar cane communities of Nicaragua can literally mean the difference between survival and death.

In response to this situation, a non-profit organisation has opened up an office in the city of Chinandega, located between the two biggest sugar producers in Nicaragua. Professionals for Social and Business Auditing (Profesionales para la Auditoria Social y Empresarial), or PASE, was formed in 2003 and is dedicated to the promotion of labour and human rights in the agricultural and textile industries of Nicaragua. PASE provides free legal aid to workers regarding their and their families’ rights to social security and other labour rights.

In the last twelve months, PASE has published a manual on social security rights for agricultural workers in understandable language and conducted training workshops of community and union leaders across western Nicaragua. It also holds training workshops on alternative skills for employment for current and former cane cutters.

For the future PASE aims to:

  • become a permanent resource for agricultural workers;
  • expand its services beyond social security assistance;
  • provide more workshops to workers and their leaders;
  • publish and distribute more copies of their manual with a view to reaching the most rural and vulnerable communities;
  • directly aid widows and orphans of deceased cane workers affected by CKDnT;
  • publish a policy paper providing concrete recommendations to government and industry on how to address the effects of CKDnT;
  • engage with the international community to identify practical solutions to this epidemic;
  • produce a short video clip explaining CKDnT and workers’ rights in an easily accessible way that workers will understand.

During their visit to PASE, Esma and Martin visited the Monte Rosa sugar cane processing plant where they spoke with union leaders and workers about the conditions of work, CKDnT and the effects of aerial spraying of pesticides. They briefly visited a newly built school located right next to the sugar cane fields which are sprayed by air. They also visited two clinics where they spoke with a doctor about the kidney disease epidemic and with other medical workers. At La Isla Community Centre they recorded an interview with all the workers at the Centre who run workshops in alternative means of income generation and give assistance in informing cane workers about their social security rights.


  • PASE (March 2016) ‘Project Proposal: PASE Legal Services Office’
  • PASE (October 2015) ‘Seguridad Social: Manual para Trabajadores Agrícolas y sus Familiares’
  • Comité Nacional de Productores de Azúcar (undated) ‘Azúcar de Nicaragua: Endulzando el Mundo’

Donations to the work of PASE can be made through the following link:–2