Anthropological Perspectives on CKDnt in Mexico: Paradigm Shifts in Social Determinants of Health
The Phenomenon of CKDnt in Mexico and the Case of Agua Caliente
In Mexico, particularly within poor and marginalized communities, individuals are experiencing kidney failure with little warning and no traditional explanation. This condition is categorized as chronic kidney disease of non-traditional origin (CKDnt), a variant that conventional etiological models—such as diabetes or hypertension—cannot account for. Instead, CKDnt is understood as a consequence of rapid economic development, environmental degradation, and precarious living and working conditions. One specific hotspot is the municipality of Poncitl!n in the state of Jalisco, which has a population of approximately people and suffers from disproportionately higher rates of chronic kidney disease (CKD) compared to the rest of the state. Within this municipality, the village of Agua Caliente on the shores of Lake Chapala serves as a primary example of this crisis. In Agua Caliente, both the young and old are affected. The Martinez family illustrates the severity of the disease: two teenage sons (David and Eduardo), their mother Lola, Lola’s brother, and her niece have all been diagnosed with CKDnt. Residents often use the idiom "ri!ones chiquitos" (small kidneys) to describe their condition, which refers either to congenital renal hypoplasia or to the extreme shrinkage of the organ due to advanced disease progression before diagnosis, which often renders biopsies impossible.
Socio-Environmental Conditions and Ecosocial Etiologies
The environment in the Lake Chapala region is described as fragile and heavily contaminated. Lake Chapala is Mexico’s largest freshwater lake and is connected to the Lerma River, forming the Lerma-Chapala Basin which supports roughly people. The lake suffers from industrial dumping, inadequate wastewater treatment, and the widespread use of unregulated pesticides and agrochemicals. For the people of Agua Caliente, the lake is central to life: it is used for bathing, washing clothes, fishing, and drawing water. However, concentrations of heavy metals such as lead (), copper (), mercury (), arsenic (), cadmium (), and uranium () have been reported in the water and the tissue of fish like carp. In households, food is cooked on homemade wood-burning stoves in poorly ventilated spaces, contributing to comorbidities like poor pulmonary health, cancer, diabetes, and alcoholism. Infrastructural failures exacerbate these issues; for example, a sewage treatment plant in San Pedro Itzic!n, constructed in 2001, flooded in 2003, 2004, and 2012, spewing raw sewage into areas where locals fish and children play. Water access is equally problematic, as even the purchased corporate and local "garrafones" ( plastic water bottles) are often contaminated with coliform bacteria including Escherichia coli, fecal matter, and arsenic.
The Political Economy and Fragmentation of Mexican Healthcare
Access to healthcare in Mexico is determined by labor relations and social insurance status, resulting in a fragmented and unequal system. Approximately of private-sector salaried workers are covered by the Instituto Mexicano de Seguro Social (IMSS), while approximately of civil servants are covered by the Instituto de Seguridad y Servicios Sociales de los Trabajadores de Estado (ISSSTE). Nationalized industries like PEMEX (Mexican Petroleum) have their own systems, and about of the population uses private insurance. Approximately half of the population is uninsured and must rely on the Secretar!a de Salud (Ministry of Health), which requires out-of-pocket payments for services. The former "Seguro Popular" was replaced by the Instituto de Salud para el Bienestar (INSABI), yet neither historical system provided comprehensive support for dialysis or transplantation to the uninsured. This system is described as an "autoconstrucci!n" (self-construction), a governmental work-in-progress that is constantly adapted but rarely finished, effectively preventing the rural and Indigenous poor from receiving entitlement. Because the labor market is flexible, citizens often cycle through different insurance statuses, making social security insecurely anchored and temporary.
The Moral and Sacrificial Economies of Care
For the uninsured, the path to renal care is haphazard and impoverishing. Patients must pay for hospitalization, surgery, biopsy needles, disinfectant, and medications. To afford these, families lobby politicians, appeal to networks of friends, sell land, and even beg. In Mexico, peritoneal dialysis (PD) is the preferred treatment modality provided by the state, but it is performed in the home, requiring family members to undergo training and transform their living space into a "paraclinical" environment. Furthermore, because Mexico lacks a robust deceased organ donation program, of kidneys are sourced from living-related donors. This creates an intense "moral economy" of obligation and altruism within kinship networks. However, the "bioavailability" of a relative’s "other kidney" is increasingly questioned in regions like Lake Chapala, where multiple family members may already be affected by environmental harms. This reliance on the poorest citizens to sustain life through their own labor and bodies constitutes a "sacrificial economy of care" that dispossesses the poor of the means to reproduce life while generating value for pharmaceutical companies and private laboratories.
Methodological Frameworks: From Social Determinants to Social Relations
This research draws on two ethnographic studies (one starting in 2011 with 134 participants and a 2017 pilot project following 12 families) to contrast the "social determinants of health" (SDH) framework with an anthropological "social relations" perspective. The SDH framework, rooted in the work of Frederick Engels, Rudolf Virchow, Richard Wilkinson, and Michael Marmot, focuses on the unequal distribution of power and goods. However, critics argue that SDH tends to be static, decontextualized, and relies on "unidirectionally arrows" that overdetermine health outcomes. Anthropologists prioritize "social relations," which are situated, temporal, and relational. This approach uses "trace data" (as defined by Carlo Ginzburg), including vernacular descriptions and media reports, to build evidentiary chains. It also employs the concept of "structural violence" (Paul Farmer and John Galtung) to describe how social structures—laws, policies, and infrastructures—become embodied as suffering. CKDnt is defined as a "wicked" and "superwicked" problem (the latter involving climate change), requiring an interdisciplinary move away from discrete causal models toward a paradigm that embraces the complexity and "liveliness" of the social.
Designing Interventions and Rethinking the Future of Care
A paradigm shift is required to move beyond conventional public health interventions that emphasize individual lifestyle or behavioral changes. The WHO suggests that major reductions in non-communicable diseases (NCDs) come from population-wide interventions, yet political and resources constraints often lead back to a focus on "healthy lifestyles," which can pathologize the vulnerable. The paper argues for "intervention otherwise," centering on community engagement and the co-production of knowledge. This includes addressing the environmental impact of nephrology itself; dialysis is a massive contributor to medical waste, using of source water to create dialysate and producing significant plastic waste. With the global dialysis population projected to reach by 2025, there is an urgent need for "green nephrology" and alternative care models. Ultimately, the authors contend that "cause" and "care" are fundamentally entangled; understanding the social conditions of disease emergence is not just a scientific necessity but a prerequisite for establishing just and effective healthcare solutions.
This article connects various individuals and institutions to the Lake Chapala community, particularly in regard to kidney disease. The primary community affected is Agua Caliente, where members, such as the Martinez family, exemplify the severe impact of chronic kidney disease of non-traditional origin (CKDnt). Infrastructural factors play a role, with inadequate sewage treatment facilities contributing to health risks. Moreover, the article discusses the fragmented healthcare access in Mexico, emphasizing how labor relations determine healthcare coverage. Key institutions include:
Instituto Mexicano de Seguro Social (IMSS): Coverage for approximately 44% of private-sector workers.
Instituto de Seguridad y Servicios Sociales de los Trabajadores de Estado (ISSSTE): Coverage for about 5% of civil servants.
Secretaría de Salud: The Ministry of Health, which relies on out-of-pocket payments for uninsured individuals.
Instituto de Salud para el Bienestar (INSABI): The replacement for “Seguro Popular” that failed to provide comprehensive support for dialysis and transplantation.
These institutions reflect the systemic issues within the healthcare system that affect those in poor and marginalized areas, defining their access to necessary healthcare services related to CKDnt and the socioeconomic realities of the region.