Postcard — April 4, 2017, 1:12 pm

Under the Surface

Investigating chronic kidney disease in Jalisco, Mexico

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Eduardito and the author’s dog. Photograph by Manuel Jacobo

On this hot day in June, Antonio Cruces Mada, the secretary of health for the Mexican state of Jalisco, doesn’t look so good. Sweat streams down his face as he stands before a crowd of about 200 residents of the Jaliscan village of San Pedro. They are seated on folding chairs, waiting for him to address the high incidence of kidney disease in San Pedro and a cluster of other villages on Lake Chapala, which lies at the eastern edge of the state. A woman opens a polka-dot sombrilla. Two others spread their fans. Men in sombreros slouch, arms knotted over their chests.

“We know there’s a health problem affecting many people in the region,” Cruces says. “There have been several studies.” The Department of Health, he says, expects to have answers in two years.

People in the crowd exchange looks of disbelief. Since 2009, at least a hundred residents in San Pedro, Agua Caliente, Mezcala, and Chalpicote have died of insuficiencia renal crónica, or chronic kidney disease, a condition characterized by declining kidney function that in its advanced stage necessitates dialysis or a kidney transplant. The majority of the village’s residents living with insuficiencia renal today are between the ages of five and twenty-four. Of the more than 1,600 kids from the area who have been screened for a study still in progress, signs of kidney disease were found in 14 percent. A similar study that was conducted in Europe found the disease in only 1.8 to 4 percent of children.

Manuel Jacobo, a thirty-year-old activist and a native of the nearby village of Mezcala, stands at the edge of the crowd. The sides of his head are shaved, the rest of his black hair caught in a low ponytail. His face—dark eyes and a nose ring like a bull’s—remains expressionless as he taps on his phone, posting snippets of Cruces’s speech to Facebook. He does not clap politely with the rest of the audience. For him, it’s too late for promises—his younger brother has been dead for two months.

Palabras,” he writes on Facebook. Words.

Manuel’s brother, Josue Jacobo Contreras, played the guitar and believed in music as activism; he especially loved the contemporary Spanish anarchist singer Lúa, who once said, “I do not want to govern or be governed. Feminism must be horizontal and self-managed.” Josue was a sworn supporter of gay rights, women’s rights, and the rights of indigenous people. He was just a nice person, Manuel tells me a few weeks after Cruces’s speech. Manuel remembers one day when Josue had a headache, though it seemed nothing out of the ordinary: he’d asked Josue to help him cut weeds in the hills, and Josue had agreed. After just a few minutes of work, Josue stopped and lay down on the ground, but when Manuel asked him how he was doing, he smiled and said he was well.

In November 2015, Josue vomited after drinking a single shot of tequila. The next day, he became short of breath, and his sister drove him to a medical center. Though he’d been suffering for several months from occasional headaches and a decreased appetite, it had never occurred to him that there might be something seriously wrong. He was young. He felt mostly fine. But when Josue told the doctor at the medical center that he was from Mezcala, the doctor guessed, correctly, that Josue’s kidneys were failing. Josue started dialysis treatment, but his condition was already terminal (because it’s often asymptomatic until reaching an advanced stage, chronic kidney disease has been dubbed a “silent disease”). Josue died five months after that visit to the clinic, at the age of twenty-three.

If he had been treated in the earlier stages of his disease, Josue would have had a brighter prognosis: his father, who works for the Secretariat of Public Education and has a large, supportive family, would have been able to gather money to pay for treatment. Other lakeside families afflicted with the illness—particularly in Agua Caliente, where a January 2017 study reported that 270 children have chronic kidney disease—are forced to sell their possessions and beg on the streets. “In the United States, ever since the 1972 End Stage Renal Disease Program took effect, if you get kidney disease, you automatically qualify for Medicare,” says Andrew Fenves, a nephrologist and associate professor of medicine at Harvard Medical School, over the phone. “The government pays for dialysis. In Mexico, that’s not the case.” Instead, if someone suffering from kidney disease has no insurance and can’t raise enough money, he dies.

Cruces tells the crowd that he’s well aware of certain rumors. “We know there’s a widespread belief that the only problem is the water.” He looks to his left for a second, toward Lake Chapala, the largest lake in the country. The surface is perfectly still, like a criminal holding his breath, awaiting the verdict. Then Cruces looks back at his audience and tells them they’re wrong. The water is not the culprit, or at least not the only one. Studies have shown no evidence, he says, of heavy metals in the water. People around me roll their eyes. When you hear “the problem is not the water” enough times, it starts to sound a lot like “the problem is the water.”

It’s widely known that Lake Chapala is toxic. The Lerma River, which feeds the lake, has been polluted by untreated wastewater for twenty years. This isn’t news and it isn’t an anomaly: an estimated 70% of Mexico’s rivers are open-air sewers, in large part because the government has failed to enforce laws defining what can and cannot be dumped into the water. According to a recent article in the online publication Mexico News Daily, the country “produces 6,700 million cubic meters of wastewater, a figure that will increase to 9,200 million cubic meters by 2030. Only 38 percent of wastewater is currently treated in accordance with regulations.” Elias Cattan, an environmental activist and the founder of a Mexico City–based architectural firm, tells me, “What you have is government in collusion with industry.”

By industry, he means the nearly 9,000 companies with facilities along the Lerma River, including Coca-Cola, Nissan, and Bimbo, Mexico’s largest bread company. “Businesses invest millions in pretending to have treatment systems,” Cattan tells me. “They prefer to fake it than to actually pay for good treatment systems. They prefer an easy fix. So what’s happening in this country is we’re killing people with our rivers. There’s no accountability.”

It’s undeniable that access to clean water is a problem in this part of Jalisco. Adriana Hernández Garcia, a Mexican social scientist and college professor who studies Mexico’s water crisis, tells me that San Pedro, Agua Caliente, Mezcala, and Chalpicote have historically remained cut off from access to services. That might help to explain why the kidney-disease epidemic has hit these towns particularly hard, and why more affluent lakeside villages aren’t suffering in the same way. That is, residents with more money and more education are more likely to receive early intervention for the illness, thanks to higher-quality and more frequent medical care. They might, for example, seek treatment for a minor condition such as the flu, and in the course of that treatment, an astute doctor might detect early-stage kidney disease. “Simply checking the blood pressure of a patient presenting for the flu can have long-term protective aspects,” says Fenves. If kidney disease is detected, medical intervention can potentially delay kidney failure, sometimes by several years. But in general, people in Agua Caliente don’t go to the doctor when they get the flu. They also don’t have many options for alternate sources of water. “These people always had Lake Chapala,” Garcia says, “and that gave them food, water, and life. A couple of decades ago, once they learned how dangerous their water supply was, they started drilling wells, but those wells have been shown to contain arsenic and other harmful elements.”

The municipal government of Agua Caliente, for example, has not purified the local well or provided a new freshwater well, so the people have no safe drinking water. According to Juan Diaz Flores, president of the village’s Committee of Potable Water, drilling a freshwater well for the town would hurt the bottled-water business of Manuel Guerrero, the son-in-law of the municipality’s previous president and a friend of its current president.

As Cruces concludes his speech, a woman shouts to him from the sidelines: “People are dying!” If Cruces is so sure the water is clean, then he should come to her house, she says, and drink the coffee she’ll make for him with water from the local well.

The crowd laughs and claps.

Cruces tries to answer, but the woman presses a plastic bottle filled with well water into his hands.

“Drink it,” she says.

He looks at the bottle. The crowd pauses. The hot air pulses in the silence. He takes a swig and swallows, his lips twitching.

Cruces responds to a few questions from the Mexican press, then climbs into his SUV and prepares to head down the road to repeat his speech to the residents of Agua Caliente. When I approach him, he exits the car and walks back toward the folding chairs with me. “Anything you want,” he says, but he keeps glancing at the road, visibly impatient to leave.

He tells me, in English, that there are only twenty-six people in the area with chronic kidney disease. (Recent studies count hundreds, though Cruces may be referring to the twenty-six who are on dialysis.) “They call us liars,” Cruces says, “but we’re not liars. We just want to know what the problem is before we start trying to solve it. Maybe the problem is nutrition. Maybe it’s cooking with wood-burning stoves. We’re replacing their stoves! Maybe the problem is genetic,” he says. “There’s a lot of inbreeding in these communities. But how could it be the water? There are people here who have been drinking from the tap for fifty years. And they’re not sick.”

Mopping sweat off of his forehead with the back of his hand, he stands and says that he’s sorry but he has to go.

Public health crises generally result from a confluence of risks, not a single cause. Heavy metals in the water may be one determining factor, but poor nutrition could be another: the villagers lack dietary education and access to healthy ingredients. Common precursors of kidney disease include hypertension and diabetes (Latin Americans are twice as likely as Caucasians of European descent to get diabetes). The villagers also suffer exposure to pesticides and herbicides by consuming fish that live in the polluted water. And yet, Cruces’s logic is riddled with holes: The local water source wasn’t yet contaminated fifty years ago, for one thing. For another, considering the abnormal incidence of kidney disease in the area, it’s likely that many people living with the illness have not been diagnosed. Furthermore, though Cruces claims that there are no heavy metals in the water, many tests have proven the presence of metals, including lead, which has been shown to cause kidney damage. Although road access to Agua Caliente improved more than a year ago, allowing for the delivery of bottled water, many families there and in the surrounding villages either can’t afford to buy water or lack the information to know that they need it.

It’s true that the problem is not just the water. The problem is poverty. But this is indisputable: A polluted water supply doesn’t help. And this is indisputable: The state of Jalisco has the second-highest incidence of kidney disease in the world.

Once Cruces drives away, Ana Becerra, an activist who is completing a master’s degree in agroecology at the University of Andalucía in Spain, takes Manuel and me to Agua Caliente. Many residents, most of whom are indigenous, make a living by growing and selling chayote, a kind of squash. Others fish for tilapia or work menial jobs in Guadalajara. Families of six or more live together in one- or two-room homes. It’s quieter here than it was just up the road in San Pedro. Less festive. Less alive.

We walk down to the lake, where pigs are bathing, their faces half-submerged. My dog wades in and tries to imitate the pigs, and we all laugh. I touch the water. Its warmth surprises me; an hour away, in Chapala, where I live, the lake water isn’t thermal. Members of a family are bathing, swimming, and washing their clothes. Mountains stand in the distance. The rainy season has begun, and the trees and grass sway green and lush. How beautiful this place is, on the surface.

Eduardo Baltazar Urcino, known to everyone as Eduardito, is twelve years old, but he’s about as tall as my seven-year-old nephew. We meet him in midafternoon on the road in Agua Caliente as he walks home with his grandmother, Juana Urcino. Juana cares for Eduardito while his mother cleans houses in Guadalajara. His jeans are too long and collect in folds on the tops of his sneakers. His belly strains against his blue polo shirt, swollen with fluids that his kidneys can’t excrete. He keeps his sad brown eyes trained mostly on the ground. Manuel takes a picture of him standing with my dog. When Manuel shows it to him, Eduardito smiles briefly.

We go home with Juana and Eduardito. Their house is full of Eduardito’s siblings and cousins, who giggle uncontrollably as soon as we walk in. The youngest sways languidly on a swing fashioned out of a bicycle seat. The house is not enclosed. It’s made of a few slabs of aluminum propped up on sticks. I’m the only one who seems fazed by the swarms of black flies. Up a small staircase, there’s one walled-off room that the family keeps sterilized, where Eduardito undergoes dialysis four times a day.

Juana tells us that Eduardito doesn’t go to school anymore. The other kids made fun of him because he smelled of urine. Now he has little respite from his life as a patient. He used to enjoy walking in the mountains and planting corn, but these days bending down causes him too much pain. He used to dream of growing up to be a doctor, but unless he gets a kidney transplant, he probably won’t live many more years.

This is not a family of activists. Like many people in these villages, Eduardito’s relatives are exhausted by the efforts of daily survival. On a phone call several months later, I press Eduardito’s father, Julian Diaz, on what he thinks about the water situation.

“Honestly,” he says, “I don’t know. I have no idea. They’re just barely starting to investigate this. Right now, everything’s going fine. Trucks are bringing in water. They’re giving the water away for free.”

In his home, I ask Eduardito a few questions about himself before he becomes overwhelmed, crosses the room to his grandmother, and buries his face in her lap. She tells me that Eduardito’s cousin has begun to show signs of kidney disease, too, and points to one member of a group of giggling girls on a bench. She looks about six. Juana says that she’s ten years old. I ask the girl what her name is.

“Estrella,” she says. It’s the Spanish word for “star.”

No one knows how rapidly her kidneys are failing. She’ll be dead in fifty days.

A week after I visit his home, Eduardito is taken to the hospital following dialysis complications and learns that he’s eligible for a kidney transplant.

“That’s wonderful news,” I say when Manuel stops by my house to tell me.

“It’s good and it’s bad,” he says. “The family will need to prove that they can spend 10,000 pesos a month on Eduardito’s medications for the rest of his life. The hospital is reviewing the family’s finances. Of course they don’t have that money. And there are only three kidneys in this area. So the kidney will probably go to someone else.”

I ask Manuel who he expects to get the kidney.

He shrugs. “Someone who has money,” he says.

Manuel is right—Eduardito won’t get the kidney. But soon his twenty-three-year-old aunt will offer him one of hers. When I check in with Eduardito’s family in March, they are still waiting for the hospital to schedule the transplant. “I’ve been praying to God and to the Virgin of Guadalupe,” his mother says over the phone. “My heart tells me that nothing bad is going to happen, and that God has not abandoned us.” She says that Eduardito keeps her spirits up by calling her at work during the day to say hi, and to reassure her. He tells her, “Mom, soon this will all feel like a dream.” Once the transplant is over, Eduardito wants a party.

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