Something is killing the sugarcane workers of Central America. In the past two decade, over 20,000 young men in Nicaragua and El Salvador have died of kidney failure – a disease previously thought to occur only in the very old. Studies have found that women and children in the area are also suffering, though less fatally. An estimated 55% of the population of one town adjacent to the country’s largest sugar mill is affected. In that town, Seventy-five percent of deaths of men between 35 and 55 years are due to kidney disease. It’s not just in Central America, though. Once the kidney failure epidemic had been identified, cases started showing up in Sri Lankan agriculture, and in the cane fields of Thailand, and beyond.

At first activists thought it was pesticides destroying workers’ kidneys, but the research was inconclusive. Further studies found occupational links: cane cutters slaved in 100-degree heat for 12-hour days without food or water. Workers were literally sweating to death, losing 2-3 pounds a day in fluids.

But data shows that better hydrated workers seem to actually suffer more. At this point, there are about a half-dozen theories about what is causing this kidney failure epidemic. One thing is clear, though: sugar cane cutters get sick the youngest and die the fastest.

If it were mine workers, we would know just what to do: we would splash the mining companies’ names in the headlines, tying them to the deaths and demanding actions. They would comply, as they did with HIV/AIDS, silicosis and tuberculosis. Some would come kicking and screaming, but investors would know which companies were on the ball. Eventually, the market would punish the bad (and late) actors.

Sugar isn’t like that. There is no one specific company to point fingers at or to shame into change. In India alone there are 550 sugar mills. Unlike chocolate companies (Nestle, Hershey, Cadbury, Mars, Barry Callebaut) which buy almost the entirety of the world’s cocoa crop every year, Coke and Pepsi purchase no more than 2% of the world’s sugar supply, often from the same small subset of refiners.  For example, Coke and Pepsi both source from the same 20 mills in India (out of 550 available), where standards are the highest. But even the mills with the highest standards are not heavily regulated. For example, of Brazil’s roughly 250 mills, about 43 are certified as ethically operated, meaning they endeavor to conserve water, reduce carbon and agrichemical emissions and abide by national labor law. A recent review found that 18 of those 43 had committed major environmental or labor violations in recent years. They simply paid small fines as penalties.

Even if regulation was strong, supply chains would still be very difficult to manage. Coke might endeavor to buy domestic sugar from Louisiana Sugar Refinery, but that refinery might source raw sugar from mills in the Dominican Republic, El Salvador and Mexico. That raw sugar, in turn, might be harvested by the mill owner, or it might be harvested by thousands of small farmers, cutting cane by hand. The white sugar in your pink C&H bags could come from the Philippines – Your Florida Crystals could come from Zimbabwe.

In short, we don’t know who to threaten or boycott to actually make a difference for cane cutters.

But there are cases where we have levers for change. The Pellas family from yesterday’s blog? That’s one. Something amazing happened when bartenders realized their mojitos were part of the problem.  More tomorrow.