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CHICHIGALPA, Nicaragua —

During the harvest season, when exhausted workers spend seven days a week cutting sugar cane, the signs of illness were hard to see at first.

It was in the offseason, on the baseball field, that some residents noticed a change. Base-stealers were lethargic. Pitchers were losing their aim. In the evening, outfielders were burning up as if standing under the scorching sun of the day.

“That’s Mosquito, now dead,” said Arnulfo Téllez Aguilera, 49, pointing to a photograph of his smiling teammates before their muscles withered, like his. “That’s my brother, Danilo, dead too.”

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Across Central America, a painful disease that affects the kidneys has killed at least 20,000 people in the past decade and has become the leading cause of deaths in hospitals among men in El Salvador. But the illness, often called Chronic Kidney Disease of unknown causes, or CKDu, is so poorly understood that it still does not have a universally agreed upon name.

Theories vary, citing a combination of possible factors, including heat stress, chronic dehydration, toxic chemicals, painkillers, sugar consumption and even volcanic ash.

There is a rare point of consensus, many researchers say: Nicaragua’s sugar-cane heartland — in particular Chichigalpa, home to the country’s largest sugar mill — has been one of the hardest-hit places in the world.

Cane-cutting fathers and sons in the same family have died, and seemingly healthy young men are quickly wasting away.

The Nicaraguan government, the country’s sugar mills, even the World Bank, which has poured tens of millions of dollars into the sugar industry here, all say that until the mystery of the disease is solved, there is little they can do to prevent the disease.

The U.S. Centers for Disease Control and Prevention (CDC) is stepping in to help with some of the most ambitious studies of the illness yet.

But the sick former sugar-cane workers have little faith that more studies will bring improvements soon. That the research will be funded entirely by the sugar industry is fueling the distrust.

“I don’t think anybody has clean hands,” said Kristen Genovese, a lawyer who helped sick former workers file a complaint against the World Bank’s lending arm in 2008 for loaning $55 million to the sugar mill here, called San Antonio, without looking into the disease or the possibility that it might be connected to the industry.

“The government of Nicaragua has done nothing to help these people,” said Genovese, who was with the Center for International Law in Washington, D.C., when she filed the complaint. And the World Bank, she argued, “should have spotted this problem, and didn’t do anything about it, and continued to invest in sugar in the region.”

No link seen

Radically different perceptions of the cause have stirred debate over who should cover the costs of treating patients with the disease.

Mario Amador, general manager of Nicaragua’s National Committee of Sugar Producers, one of the groups financing the CDC studies, said the sugar-cane business in Nicaragua had quadrupled in the past 10 years into a $500-million-dollar-a-year industry, supplying everything from Coca-Cola to rum makers.

But he said the annual kidney exams, which he called necessary to avoid putting sick workers at additional risk, had created the false impression that the mills were linked to the disease.

“I don’t think there’s any relationship between CKD and the sugar-cane industry,” Amador said.

Executives at the San Antonio mill say they also take the annual test, but it is rare that they fail. “We drink the water here, too,” said Álvaro Bermúdez Castillo, the mill’s administrative director, who has been working at the mill since the 1970s.

Lawmakers in El Salvador and Sri Lanka, where similar kidney problems have emerged, have moved to ban certain herbicides.

But few of the researchers who are focusing on Nicaragua — which has the highest death rate from the disease, according to the Pan American Health Organization — are willing to say the answer is that simple.

Agricultural chemicals alone, they say, do not explain why the disease has been detected in some Nicaraguan miners at similar rates, why women who grew up on the sugar mill’s grounds have generally been unscathed, or why workers here are affected at much higher rates than people exposed to the same chemicals elsewhere.

“The problem is, this is a silent killer,” said Aurora Aragón, a Nicaraguan researcher.

Residents say they began noticing the sickness shortly after the Nicaraguan government, which had nationalized the sugar industry, returned the mills to private owners in 1992.

As the operations at San Antonio rapidly expanded, driven partly by U.S. and European appetites for sugar and a move into ethanol production, families say the cane cutters grew sick in larger numbers.

The mill says it pays the government every year so that workers can receive pensions and health insurance. Without a scientifically decisive link to the disease, industry officials question why they should be responsible for more.

Overlooked disease

Throughout the early 2000s, lawsuits seeking compensation from the mill mostly went nowhere. Then in 2008, a workers’ group known as the Association of Chichigalpinos for Life filed the complaint against the World Bank’s lending arm, known as the International Finance Corp. (IFC), which had lent the mill $55 million. The complaint alleged that by failing to acknowledge the disease in documentation about the project, it had violated its own lending standards.

When deciding whether to invest in the industry, no one had brought up or looked into the disease, a spokesman for the finance corporation said. “CKD is not a common disease in the sugar sector worldwide, so IFC did not look into this issue at appraisal,” said the spokesman, Aaron Rosenberg, based in Washington.

After the complaint, the mill agreed to provide food and other assistance to widows and sick workers. It also agreed to open its door to outside researchers.

Yet “nature can be very reluctant to give up its secrets,” said Daniel Brooks, a researcher from Boston University, which was selected to investigate the disease by a committee that included sick workers and mill executives.

Five years later, Brooks has as many questions about the disease as answers. His report published in 2012 neither entirely ruled out nor formally endorsed any theory.

Now, Brooks and his team from Boston University will be leading the charge in three CDC Foundation studies, which he believes could have implications far beyond Nicaragua. Research into work-related risk factors is also planned, but sugar-industry funding so far covers only preliminary work.

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