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The study, with its renewed suspicions of a toxin-based etiology, formed the basis of the new health minister’s stance on CKDu. “The evidence suggests agrochemicals and pesticides as possible associated factors and this has to be investigated,” said Rodríguez in a 2013 interview with MEDICC Review, a Latin American health journal. Press coverage of the issue around this time tended to follow the government’s lead, suggesting in article after article that there was a potential link between pesticides and the epidemic. During this time, researchers like García-Trabanino and Wesseling say they began to worry the public was being served a convenient narrative, one that provided an easy answer — but wasn’t supported by the science.
In April of 2013, El Salvador hosted a meeting of the Council of Ministers of Health of Central America and the Dominican Republic, which culminated in the signing of the Declaration of San Salvador, which recognized CKDu as “a major public health problem,” and signaled a willingness to tackle the epidemic on a regional level. Before the document was signed, however, a vigorous debate broke out amongst the attendees over whether the role of pesticides was being overstated. According to an account of the meeting by the Center for Public Integrity, representatives of El Salvador’s ministry of health asserted that the most compelling data suggested a high association between CKDu and agrochemical exposure, while other researchers, including García-Trabanino, argued that a definitive link had never been established in the scientific literature. Rodríguez put an end to the debate by declaring, “What has been presented here is scientific fact, and I will defend it with my nails!” She showed the crowd a set of brightly painted red nails, the room erupted with laughter, and the document was signed.
But the debate over the role of pesticides did not end there. In the summer of 2013, Rodríguez and Salvador Menendez, the mayor of a municipality called San Luis Talpa that had been devastated by the epidemic, launched a campaign to prohibit the use of 53 agrochemicals that were suspected of being deleterious to workers’ health. The proposal ignited a fierce public discourse, whose fault lines hewed closely to what had been argued by each side in the Council of Ministers meeting. But as the scientific debate entered the public realm — through press coverage and word of mouth — the conversation quickly soured, before finally exploding into outright acrimony and accusation.
The mudslinging went in all directions: García-Trabanino accused the health ministry of distorting science in order to score a tidy political victory. The powerful agricultural sector, according to a newspaper article at the time, made sensational claims that El Salvador’s agricultural output would plummet by 80 percent if the ban went through. Orantes says he was maligned as an “eco-fanatic” who was “obsessed with agrochemicals.” In turn, García-Trabanino says he was publicly disparaged as being a shill for the agricultural sector (he insists he never took money from agricultural groups) and was so widely vilified that Julio Miranda had to warn him against returning to Tierra Blanca, where he had been conducting research. The fieldworkers whose health had been the focus of his career were now a threat to his safety. García-Trabanino says he received a death threat during this time. For Mayor Menendez it was even worse: He claims that on three separate occasions, the armored car he was riding in was fired upon by unknown assailants. Each time, he notes, he escaped without injury.
On September 5, 2013, El Salvador’s legislative assembly voted to approve the agrochemical ban. But in a move that surprised many, President Funes himself declined to sign the prohibition into law, instead returning it to the legislative assembly where it entered a state of legal limbo, neither vetoed nor approved. (In 2016, Funes was embroiled in a corruption scandal that prompted him to flee to Nicaragua, where he was granted asylum. He maintains that he is the victim of political persecution.) The degeneration of the public debate and the failure of the agrochemical ban to become law marked the end of what many had hoped would be a high-water mark for CKDu research and action. After that, in 2014, a new administration took power, and Rodríguez, who was over 90 years old, retired from her role as health minister. Orantes’s investigative unit was dissolved, and he was reassigned to a different department. An effort to revive the agrochemical ban foundered, a national action plan that Orantes had developed was cast aside, and the stipulations of the Declaration of San Salvador — which many believed had offered the brightest hope for regional action to combat the epidemic — went largely ignored. It was a “regression that left us in an even worse state than when we started,” recalled Orantes.
When his grandfather died of kidney failure in 2005, José Lopez, like most people in Tierra Blanca, had never heard of CKDu. But in the years that followed, insuficiencia renal, as it became known, grew into a dominant feature of life in the Bajo Lempa. Billboards sprung up along the highway connecting the region to San Salvador, advertising private dialysis clinics that few could afford. Local funeral homes began catering almost exclusively to victims of CKDu. (“It’s very rare for someone to die from a different disease,” one mortician said in an interview with Undark.) Nearly everyone was touched, directly or indirectly, by the epidemic. Many field laborers were diagnosed but continued working — compelled to by the grinding poverty endemic to the region. Doctors often dispensed paradoxical advice: Reduce work hours and purchase costly medication.
By the 2010s, the disease was ravaging the Lopez family. One of Lopez’s uncles had succumbed in 2009 and now rested beside Juan-Francisco in the Tierra Blanca cemetery. Two more uncles were sick, as was Lopez’s father, Vitelio. Worst of all, though, was that both of Lopez’s younger brothers had developed the disease — Francisco at the age of 10.
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