Chronic kidney disease in Central American agricultural communities: challenges for epidemiology and public health.

This paper contextualizes the chronic kidney disease epidemic and related burden of disease affecting Central American farming communities. It summarizes the two main causal hypotheses (heat stress and agrochemicals), draws attention to the consequences of dichotomous reasoning concerning causality, and warns of potential conflicts of interest and their role in "manufacturing doubt." It describes some methodological errors that compromise past study findings and cautions against delaying public health actions until a conclusive understanding is reached about the epidemic's causes and underlying mechanisms. It makes the case for a comprehensive approach to the historical, social and epidemiological facts of the epidemic, for critically assessing existing studies and for enhanced rigor in new research.