Abstract
Objectives: This paper highlights and discusses major factors affecting Salvadoran farmers’ involvement in National Health System-led efforts to prevent MeN in El Salvador and includes some recommendations to enhance their involvement. Methods: The study, conducted in El Salvador in June 2018, involved 10 life-long farmers residing in five MeN-affected communities in Chalatenango and Usulutan Departments who were either MeN-free or MeN-controlled, to understand through semi-structured, qualitative interviews their experience of participation in broader epidemic control efforts. Complementary interviews held with two nephrology teams and a senior representative of the grassroots-level National Health Forum operating in the same area, provided necessary contrast. Interview questions were informed by reference to the Adaptation and Development after Persecution and Trauma (ADAPT) model [1] as applicable in post-conflict environments like El Salvador to analyze contextual factors influencing community participation. Findings: Farmers are scarcely involved in wider MeN prevention efforts in El Salvador despite greater National Health System emphasis on encouraging community participation since the approval of the 2009 Health Reform [2]. This study found that widespread insecurity due to gang warfare, declining family and social networks due to high murder rates and international migration, and unresolved sense of injustice over unremitting poverty are among major factors with potential destructive effect on farmer participation. Conclusions: Health system-led MeN prevention responses need to encompass attention to persisting social vulnerabilities in economically and socially marginalized communities in order to enhance farmer participation in this effort. This paper concludes with some recommendations on how this can be done.
Highlights
Since 2002, different sources of health information in El Salvador have been calling attention to the high rate of deaths in rural communities by a variant of Chronic Kidney Disease (CKD) in which traditional causes, such as the presence of comorbidities like diabetes mellitus and hypertension, are not necessarily part of the clinical picture [3] [4] [5] [6]
Its widespread in the region has led to the epidemic being referred to as Mesoamerican Nephropathy (MeN) or Chronic Interstitial Nephritis of Agricultural Communities (CINAC) in regional scientific circles
Some South American countries, as well as countries like Sri Lanka, India, and Egypt have registered an epidemic with similar features [9], where the disease is known as Chronic Kidney Disease of Unknown Etiology (CKDu)
Summary
Since 2002, different sources of health information in El Salvador have been calling attention to the high rate of deaths in rural communities by a variant of Chronic Kidney Disease (CKD) in which traditional causes, such as the presence of comorbidities like diabetes mellitus and hypertension, are not necessarily part of the clinical picture [3] [4] [5] [6]. Recent epidemiologic reports published by the Ministry of Health of El Salvador (MINSAL) do not reflect the specific mortality rate due to MeN, but, rather, the sum total of hospital deaths caused by CKD based on the combined total of different CKD-related diagnoses, including MeN. The MINSAL registers between 500 and 700 new cases of kidney failure annually [11] Given this high rate, and taking into consideration that, as Dr Garcia-Trabanino points out the published statistic does not reflect the full reality regarding deaths by MeN, in that most of those affected die in the anonymity of their own homes [10], the concerned Ministry as well as its partners in the Pan American Health Organization (PAHO) has declared the MeN epidemic as a still unresolved public health emergency [12]
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