Is There a Place for Environmental Justice in Global Health?

Orestes Gutierrez was angry.¹ This wasn’t unusual. He arrived agitated to most every general assembly of the Asociación Montelimar Bendición de Dios (AMBED). AMBED is a Nicaraguan environmental justice organization composed of more than 300 current and former employees of a sugarcane plantation owned by the Montelimar Corporation.

AMBED’s general assemblies usually take place on Sundays, in a shaded area on a hill near a highway that parallels the Pacific coast. From this hill, the Montelimar plantation still looks much as it did in the 1970s when Nicaraguan dictator Anastasio Somoza Debayle kept a vacation home on the picturesque beach nearby. Somoza, who was, among other things, a sugar baron, built many of the dams, irrigation systems, and wells that have helped ensure that sugarcane remains a lucrative part of Nicaragua’s agricultural economy, even as other crops—cotton, wheat, and fruit—have become less and less viable.

The sugarcane monoculture is almost sublime in its vast greenness, its oppressive heat and humidity, and its stark inequality. Generations of men and women like Orestes have found seasonal employment planting, irrigating, fumigating, burning, and harvesting the cane, often while maintaining their own family farms.

Orestes was angry, in part, because he was sick. Like thousands of other sugarcane plantation workers, he had been diagnosed with a novel form of chronic kidney disease. Chronic kidney disease, a progressive and terminal condition, often results from diabetes or hypertension, but Orestes and the others were not diabetics. They did not have high blood pressure. They had been diagnosed with “chronic kidney disease of non-traditional causes,” or CKDnt. But it wasn’t just the terminal diagnosis that angered Orestes. He was also angry because he had heard over and over again—too many times, as far as he was concerned—that the cause of CKDnt was a “mystery.”

Solving that mystery has attracted a host of experts to Central America, where several studies by epidemiologists and nephrologists are ongoing. As a medical anthropologist, I am sometimes asked by these global health experts how the complexities of epidemiological research—its slow speed, its technical limitations—might be better translated for people like Orestes and grassroots organizations like AMBED. I frequently hear some version of the frustrated lament, “It’s hard for these people to understand.”

But as far as Orestes and AMBED’s environmental justice activists were concerned, there was no mystery about this disease.

For Orestes and many others, the causes lay in the plantation landscape itself. Occupational health experts compare the work of planting and harvesting sugarcane to running a half marathon in 90-plus degree weather, going home and going to sleep, and doing the same thing again for the next five days. Even though this is physically taxing work, there are no other jobs as reliable as this one in this part of the world. In 2013, Orestes arrived at the offices of the Montelimar Corporation ready to begin another harvest season, just as he had done since he was 13 years old when he joined his father and uncle as a cabra (literally, “goat”), a kind of unofficial apprentice.

But Orestes did not join the harvest that season. For decades, a medical exam had been a prerequisite for employment at the plantation. Tests on Orestes’s blood revealed unusually high concentrations of creatinine. Creatinine is a waste protein secreted during muscle metabolism and, under normal circumstances, filtered out of the body by the kidneys. Elevated creatinine levels are a key biomarker for kidney failure. When he was dismissed, Orestes wasn’t given access to his medical records, and he didn’t get much of an explanation from the Montelimar Corporation’s medical staff. He received no advice about how to access retirement or social security benefits guaranteed to him by the state. Over the course of the late 1990s and early 2000s, Orestes and hundreds of other would-be workers, some with more than 20 years of experience cutting cane, were similarly dismissed.

A standard diagnostic form necessary for obtaining social security benefits requires doctors to state whether a worker’s disease is “occupational” or “common.” In Orestes’s case, the doctors called it “common,” meaning that he did not qualify for disability benefits. It was this wave of brazen dismissals that turned CKDnt into an environmental justice issue and, eventually, a place-based environmental justice movement. The rise in CKDnt became a call to address the combined effects of decades of landscape modification, exploitation, and marginalization. This environmental justice movement now finds itself in an awkward engagement with the science and practice of global health.

Orestes helped to launch AMBED in 2014. That year, the World Bank’s International Finance Corporation (IFC) was preparing a multimillion dollar loan that would allow the Montelimar Corporation to expand its operations. Aided by international environmental lawyers, AMBED filed a grievance before the IFC’s Compliance Advisor and Ombudsman (CAO). The grievance asserted that plantation working conditions were to blame for the epidemic. Similar to a CAO complaint filed in 2008 by another Nicaraguan workers’ group, the AMBED grievance went beyond the disease. It also mentioned the long-term inequities and environmental costs of sugarcane plantation production: low pay; poor record keeping; exposure of people, plants, and animals to aerial pesticides; land tenure insecurity; and a lack of consistent access to potable water. Though it was filed with an arm of the World Bank, AMBED’s grievance was a place-based document.

In 2016, AMBED entered a series of CAO-mediated dialogues with the Montelimar Corporation, designed to search collaboratively for a resolution. In these dialogues, the CKDnt epidemic quickly upstaged concerns about water quality, air pollution, and land tenure. Among AMBED’s early achievements was an agreement by the Montelimar Corporation to subsidize CKDnt patients’ journeys to dialysis clinics in Managua, an hour’s drive by bus. Dialysis patients spend three of every seven days going to dialysis, receiving dialysis, or returning from dialysis.

For Orestes, these concessions were hopeful, but they were still not enough. Frustrated by the slow pace of the mediation process, he resigned his position in AMBED’s leadership. Still, he attended the regular general assemblies, where the remaining leaders would update the membership on the progress they had made, including reinstating social security payments that had been denied to dismissed workers, finding alternative employment opportunities for ex-workers and their families, and, of course, searching for answers to the question of why so many people were getting sick. To its credit, the company continues to return to the dialogue table.

By the time of AMBED’s founding, the CKDnt epidemic was already well known in Nicaragua and across Central America. Since then, high-profile, internationally funded studies of CKDnt have brought people like Orestes into closer contact with epidemiologists and doctors from as far away as Sweden, the United Kingdom, and the United States. Though Orestes, like many others in Nicaragua, was initially convinced that the regular application of pesticides from drones and helicopters was infusing water, soil, and crops with nephrotoxic poison, little hard evidence has emerged to support this claim. Some studies have found that the heat exposure and chronic dehydration that result from one of the world’s most strenuous jobs put excessive strain on the kidneys, leading to CKDnt, but those claims, too, are hard to verify.

Given the lack of a clear explanation, news reports frequently describe CKDnt as a “mystery disease.”

Orestes didn’t like that.

“I worked cutting cane for 40 years,” he told his fellow AMBED members in November 2017. “And in one of my last years, I saw a group of students from the National University out here supposedly studying this disease that affects us… And it pains me, and it’s awkward to open my mouth and speak in such crude terms about people who supposedly are doing research, but they’re researching to fool us! They think we’re ignorant, but we’re not ignorant.”

Orestes was naming a key dilemma not just for AMBED but for many environmental justice (EJ) movements. EJ movements tend to revolve around two poles: long-term, place-based inequality and novel disease epidemics. Frequently, the causes of those epidemics, from cancer in Louisiana’s chemical corridor to asthma in Houston to the epigenetic effects of PCBs in the Great Lakes, are shrouded in uncertainty. And just as frequently, those affected by disease are asked to play the role of patients. They are asked to defer to the expertise of better-connected and better-educated researchers and doctors. People like Orestes are also asked to be patient—to “try and understand”—the technical challenges of disease detection.

Doctors and advisors frequently tell workers that CKDnt is “multifactorial.” Two factors that seem to correlate with the disease, at least in Nicaragua, are poverty and hard agricultural labor. The accumulated intergenerational biological, social, and psychological burdens of decades of intense monoculture are as hard to quantify as they are to mobilize against. After all, the Montelimar Corporation is only the most recent owner of this plantation. This industrial landscape, a product of dictatorship and exploitation, is older than the company, older than the IFC and the World Bank, older than Orestes.

In the United States, which remains the center of much EJ scholarship and activism, legal and quasilegal negotiations, similar to those in which AMBED and the Montelimar Corporation are involved, are key EJ mechanisms. Such negotiations depend on the assumption that at the dialogue table, everyone has an equal voice. But as place-based problems become biomedical problems, members of EJ movements can feel compelled to defer to the expertise of biomedical authorities. Others, like Orestes, may simply feel themselves being taken for ignorant “fools.”

The case of CKDnt and AMBED is unlike previously documented EJ cases in one important respect. In the case of CKDnt, a legalistic approach to EJ, rooted largely in experiences within the industrial United States, is meeting up awkwardly with a humanitarian and techno-interventionist global health approach to disease that has been largely exported from the United States and Europe to Latin America, Africa, and Asia. CKDnt is not only a problem for Central American sugarcane plantation workers. It is now considered an emerging global health crisis, affecting workers in Central America, Sri Lanka, India, and Egypt.

Orestes doesn’t represent AMBED as a whole, but his frustration comes from watching a movement aimed at solving a set of place-based concerns—about water access, about pesticide use, about labor relations, and, of course, about disease—risk becoming drawn into the orbit of global health. Orestes’ sense that he is being “fooled” by well-meaning health researchers indicates that, for him, the promise of solving a medical mystery is not enough. As yet, there is no clear place for environmental justice in global health.

AMBED members find themselves in what EJ scholar Kim Fortun calls a “double bind.”  To draw attention to their struggle, they must try to occupy two contradictory positions at once. To have a voice before the Montelimar Corporation, they must act as political subjects, with historical and geographical ties to a company and a place, and with legal entitlements to workplace protections, healthcare, and social security conferred to them as citizens of Nicaragua. To be sure, such protections exist, but the main source of public benefits to injured workers, the National Institute of Social Security, is at risk of becoming insolvent within the next two years. As more workers across the country face CKDnt and push for insurance benefits, Nicaragua’s social security crisis continues.

To gain the attention of global health scientists and advocates, on the other hand, Orestes and his comrades must act as victims: passive subjects in need of a life-saving expert solution to the “mystery.” Even though studies of CKDnt on sugarcane plantations are now ongoing, Orestes and others rightly wonder whether the search for that solution might be excusing the “slow violence” of decades of exploitation and environmental degradation in Nicaragua’s sugar plantation zone. Some fear that the corporation might prey on the patience that they have thus far displayed—that it might hide behind the growing number of (as yet inconclusive) studies of CKDnt and continue to sow epidemiological doubt along with its yearly crop of sugarcane.

Indeed, this is already happening. Nicaragua’s sugarcane corporations (there are four operating in the country at the moment) have consistently suggested that CKDnt is not a problem of labor conditions, but of laboring discipline. Company officials have asserted that some combination of lifestyle and genetic factors must be to blame. Perhaps the workers who are sick or dying with CKDnt drank too much alcohol after work or consumed too many sugary drinks to beat the heat while on the job. Perhaps they took too many non-steroidal anti-inflammatory drugs to dull the pain of over-exertion. (High doses of NSAIDs can compromise kidney function.)

My work has taken place in the shadow of AMBED’s activities, and I have aided them in obtaining a small grant and introducing them to other scholars. Though I have not been a party to the CAO mediation, I find much to admire in the willingness of ex-plantation workers to sit across a dialogue table from representatives of their former employers, knowing that at the end of the dialogue, the company’s representatives will continue to be more politically influential, wealthier, and better educated than they are. AMBED’s trust in the process of nonviolent mediated settlement is, I think, a legacy of the pragmatic, inclusive popular Sandinista revolution that toppled the Somoza dynasty in 1979. The group’s willingness to make its general assemblies a safe, democratic space in which members like Orestes feel welcome to vent their anger is another such legacy.

Lately, I have been thinking quite a bit about the term “accompaniment.” In Nicaragua, accompaniment (acompañamiento) also has roots in the revolutionary period. It referred then to the work of international solidarity activists who chose to defy the U.S. effort to undermine the Sandinista cause by joining the poor in agricultural labor, education, and healthcare. Like Orestes, I am frustrated, and I plan to continue giving AMBED my support.

Accompaniment does not alleviate inequality. What accompaniment can do is permit the brief, partial sharing of hope, fear, and—importantly—ambivalence. All three, for better or worse, are unavoidable elements of nonviolent conflict resolution, environmental justice, and, if you’re paying attention, global health. Though both patients and patience are wearing thin, AMBED is dedicated to working through double binds, rather than attempting to escape them.

Editor’s note: This piece has been updated from an earlier version published on February 8, 2018.

Featured image: Sugarcane planting, Montelimar Plantation. Image by Alex Nading, 2017.

Alex Nading is a Senior Fellow at the Watson Institute for International and Public Affairs. He is a medical and environmental anthropologist who studies the entanglement of human lives with the lives of nonhumans, particularly dengue mosquitoes, dengue viruses, microbiota, and toxic chemicals. He has been doing ethnographic fieldwork in Nicaragua since 2006. Alex is the author of Mosquito Trails: Ecology, Health, and the Politics of Entanglement, published by the University of California Press. Website. Twitter. Contact.

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1. Orestes is a psuedonym. ↩