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Quezalguaque, Nicaragua might not be a familiar location to many Brookline residents, but the two cities have been connected with each other for almost twenty-five years through the Brookline Sister City Project. And with a mysterious and complex medical epidemic currently affecting the Central American municipality, the Brookline community and Boston University have been working together to find a solution.

In 2006, Brookline and the BU School of Public Health (BU SPH) came together and sent a team of four BU SPH students to conduct a survey about the general health needs of the people in the Quezalguaque region. Another team went down the next year with a grant from Colgate-Palmolive to study the effects of hand washing. In 2008, a group went down to study the prevalence of chronic kidney disease (CKD), and to try and determine some of the causes. The results were alarming. 

“It was fifty-two times the U.S. rate [for 18-39 year old males with stages 4 and 5 CKD],” said Peter Stringham, a member of the Brookline Sister City Committee (BSCC) and retired physician. “For 40-59 year old males, it was one hundred and thirty times the U.S. rate.

“As a doctor, I first heard about [the rates], and I thought, ‘They’re wrong. This cannot be true. They’re misdiagnosing it.’”

Overall, twenty percent of males and eight percent of females tested had signs of significant CKD, but no concrete cause for the high rates was found. Water contamination was ruled out, as was high blood pressure and diabetes, two of the more common causes of CKD in most of the world. CKD is also normally found among the elderly, not among those in their 20’s and 30’s, which was the case in Quezalguaque. 

The issue quickly became a hot topic in Nicaragua, with people falling into one of two camps. A large number of those with the disease had worked at a sugarcane plantation owned by Nicaragua Sugar Estates Limited (NSEL). They claimed the high rates were due to exposure to something by the company. The company denied that, and instead blamed the prevalence of a home-brewed, moonshine-like alcohol in the area. Finding a cause, and eventually, a treatment of CKD became especially crucial, because testing positive for it makes a person unemployable for agricultural jobs in a region where it is virtually the only industry. 

“It’s especially difficult, because [CKD] takes away the breadwinner of these families,” said Daniel Brooks, BSCC member and associate professor of epidemiology at BU SPH. “There are few employment opportunities outside of agriculture.”

Partially as a result of the BSCC study and his own prior experience in the area, Brooks was selected by the World Bank in 2008 to lead an unbiased investigation into the causes of CKD in the region. The study set out to discover if there were work practices or chemicals being used at an NSEL plantation that were associated with CKD. Workers were tested at the beginning and end of the 2009-2010 harvest, and the labor practices of the plantation were observed. However, the study found no conclusive evidence to explain the high rates of CKD among the agricultural workers. Brooks noted that although the NSEL was very cooperative with the study, there was no way to know whether or not they had adjusted their labor practices because of the investigation.

Though the funding from the World Bank ends in February 2012, Brooks seemed optimistic that sponsors for future research will be found, as the issue is “starting to get the attention it needs.”

Both Brooks and Stringham agreed that further studies are necessary to try to eliminate a number of potential causes of CKD, a disease which is still not well understood. Brooks noted that he’d like to look into rates of CKD in non-sugarcane agricultural workers, the use of medications in the area, and the role of dehydration. Stringham and the BSCC team are currently conducting hypertension studies in Quezalguaque.

“It feels like when the AIDS epidemic came out,” said Stringham. “You had all these theories running around, nobody knew [anything]. It was a completely new disease. As people finally figure it out, then you can diagnose and treat.”