Health and Human Rights with regard to Sanitation

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Health and Human Rights with regard to Sanitation

April 2013

Jorge Queiroz

Introduction

The scope of this paper is to provide a general dimension of what I

consider to be one of the most vital and fundamental areas to human physical and

mental health, and needless to say standard of living, which is conventionally

known as sanitation1, with particular attention to how it is dealt with in Brazil, from

a human rights, health and legal perspectives.

Health, human rights and law have an extensive, long, intertwining and

complex relationship internationally, and water and sanitation occupy a vital space

in this field. When we speak of poor water quality and sanitation (which are

directly interrelated), we speak of illnesses, poverty and risks to society. Lack of

sanitation infrastructure also leads to devastating environmental problems, such

as destruction/pollution of water sources (rivers, lakes, phreatic surface, and water

basins), sea/shores, soil (agriculture) and air.

This particular area represents a major problem for developing and

underdeveloped countries2 – 2.6 billion3 low-income people are still without access

1 WHO definition: Sanitation generally refers to the provision of facilities and services for the safe disposal

of human urine and feces. Inadequate sanitation is a major cause of disease world-wide and improving sanitation is known to have a significant beneficial impact on health both in households and across communities. The word 'sanitation' also refers to the maintenance of hygienic conditions, through services such as garbage collection and wastewater disposal. 2 World Bank/Global Practice Team Sanitation – The Political Economy of Sanitation: How can we increase

investment and improve service for the poor/2011 – There is ongoing concern that governments, at many levels, are not devoting enough attention and resources to sanitation services. Existing sanitation investments and service provision rarely place sufficient stress upon the distinct and urgent needs of the poor. Enhance the design, implementation, and effectiveness of operations that provide pro-poor sanitation investments and services. The ultimate goal is to improve health and hygiene outcomes. The Action Framework stresses the importance of strengthened relationships of accountability among citizens, civil society organizations, and government and other service providers. While studies came across evidence of corrupt practices and rent-seeking behavior, it was overall not identified as the predominant feature distorting sanitation investment decisions. There is evidence that civil society and the private sector not only can contribute to strengthening accountability but also can be reliable and trusted partners for delivering sanitation services and creating community demand for sanitation provision. 3 Human Development Report 2006 (UNDP 2006) – about half of the world’s population lack access to basic

sanitation.

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to improved sanitation worldwide4. Among the diseases caused by poor water

quality and sanitation are: diarrhoea, dengue fever5, hepatitis A, arsenicosis,

cholera, fluorosis, intestinal diseases, leptospirosis, malaria, schistosomiasis,

trachoma, typhoid.6 These illnesses will generate a host of other health problems,

many times causing permanent damage upon those infected, including death.

Over one-third of the world's population has no access to sanitation

facilities.

In developing countries, about 80% of illnesses are linked to poor water and

sanitation conditions.

At any one time, half of the world's hospital beds are occupied by patients

suffering from water-borne diseases.

1 out of every 4 deaths under the age of 5 worldwide is due to a water-

related disease.7

Case Analysis - Brazil

Improvement in water and sanitation infrastructure is at the top of the

agenda in Brazil8. Sewage is the main cause of water and soil contamination in

Brazil’s metropolitan areas and has a significant impact on the society as a whole,

more so on the poor living in its slums9 (favelas10), generating major health

4 WHO/UNEP – Going back in history, before the industrial revolution, it was possible to withdraw and

consume water to everyone’s satisfaction However, times have changed as demographic pressure in the last three centuries (for example, 1 billion inhabitants in 1800, 2 billion in 1900 and 6.6 billion at the end of 2007) no longer allows for the management of water without cooperation among communities. 5 Centers for Disease Control and Prevention – CDC reports that with more than one-third of the world’s

population living in areas at risk for transmission, dengue infection is a leading cause of illness and death in the tropics and subtropics. Dengue Fever (DF) and Dengue Hemorrhagic Fever (DHF) 6 WHO/UNICEF 2012

7 The Water Project – NGO 2012

8 Diverse legislation has been introduced in Brazil since late 1990’s.

9 UN 2012 defines slum as a run-down area of a city characterized by substandard housing, squalor, and

lacking in tenure security, combining to various extents the following particularities: inadequate access to safe water; little or no access to sanitation and other infrastructure; poor structural quality of housing; overcrowding; and insecure residential status (lack of personal/community land ownership). Slums are usually inhabited by the very poor or socially disadvantaged. Slum buildings vary from simple, one to multi-layered, shacks to permanent and well-maintained structures. About one billion people worldwide live in slums and this number is expected to double by 2030 10

Brazilian Institute of Geography and Statistics (IBGE) Demographic Census 2010 – 11.425.644 people in Brazil (6% of the population) live in subnormal poverty clusters - slums (favelas), property invasions, gullies, swamp houses, and the like. These types of poverty concentrations are also formed by narrow alleys of difficult personal access – and access by any public service. The lack of services such as routine garbage collection allows rubbish to accumulate in huge quantities. The lack of infrastructure such as sanitation is

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problems – over 11 million people live in poverty clusters in Brazil (6% of the

population)

The vast majority of the population in Brazil live in metropolitan centers

and less than 20% of the sewage produced in urban areas is treated11, one of the

reasons being that slum dwellers do not have legal title of the land. Sewage that is

not treated ends up every day ‘in natura’ in rivers, lakes, hydrographic basins and

sea, with severe damage to the environment and health12.

In order for Brazil to reach universal access to sanitation, it would need

to invest substantially more than today – that is, 0.63% of GNP ($15.6 billion/year)

when a mere 1/3 of that ($5.4 billion/year) is currently invested.13 Only half of the

population has access to sewage collection system14 – in other words, roughly 100

million men, women and children in Brazil do not have access to this basic human

right to health, essential to their dignity. About 25% of the population does not

have access to treated water.15

Advances made in the last decades were largely offset by the rather

high rate of population growth, among other reasons – such as political resolve, for

instance.

“In socially and economically dynamic Brazil, persistence of sanitation

problems, although decreasing over time, remains a source of

embarrassment, as sanitation (especially sanitary sewerage) is

associated with modern society.”16

To put it into perspective, Brazil’s population went from 50 million to

almost 200 million people from 1970 to 2012 respectively. It is still characterized

by its dramatic inequality and concentration of income – in 2010 half of its families

also caused by the informal nature of settlement. Informal settlements also face the brunt of natural (tropical storms) and man-made disasters, such as floods and landslides. 11

Agencia Nacional de Aguas/ANA – Brazil’s National Department of Waters 12

ANA Brasil 13

IBGE 2010 – Istituto Brasileiro de Geografia e Estatistica / Brazilian Institute of Geography and Statistics – Síntese dos Indicadores de 2009 14

IBGE 2008 – Instituto Brasileiro de Geografia e Estatistica / Brazilian Institute of Geography and Statistics – Pesquisa Nacional de Saneamento Basico – National Data about Sanitation – In 2008 56% of domiciles did not have access to sewage collection. 15

Ministry of Cities, Department of Sanitation - SNIS 2010 – Sistema Nacional de Informacoes em Saneamento 2010 16

The World Bank – WSP/Water and Sanitation Program, The Political Economy of Sanitation – February 2011

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lived on less than US$ 200 per month; the 10% richer accounted for 45% of total

income while the 10% poorer accounted for only 1%.17

Dengue Fever and Dengue Hemorrhagic Fever18

Dengue fever19 (transmitted by the Aedes Aegypti mosquito which

belongs to the same family of that of yellow fever20) is directly linked sanitation

problems.

Dengue has emerged as a worldwide problem only since the 1950s and

it is endemic in Latin America and Southeast Asia.21

17

IBGE – Instituto Brasileiro de Geografia e Estatistica / Brazilian Institute of Geography and Statistics 18

See supra, page 1, introduction 19

Dengue fever is one of the main public health problems on earth (Brazil’s Ministry of Heath). 20

Instituto Oswaldo Cruz. Existence of the dengue virus in Brazil was proven by laboratorial analysis only in 1982. From 1982 to 2011 four types of dengue virus were identified. There is no vaccine to prevent dengue in the world. 21

WHO 2012

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The incidence of dengue has grown dramatically around the world in

recent decades. Over 2.5 billion people – over 40% of the world's population – are

now at risk from dengue and as many as 100 million people are infected yearly. An

estimated 500 000 people with severe dengue require hospitalization each year, a

large proportion of whom are children. About 2.5% of those affected die.22

The threat of a possible outbreak of dengue fever now exists in Europe

and local transmission of dengue was reported for the first time in France,

Portugal, Croatia and other countries.

Aedes Aegypti Mosquito (Dengue Mosquito)

Dengue Fever in Brazil

Dengue fever reappeared in Brazil in 197623 and became critical in the

end of 1990s due to the fact that traditional methods employed were not effective

and that the dengue mosquito adapted quite well to the new environment created

by the accelerated disorganized increase of urban areas and corresponding

number of informal settlements (favelas and the like) together with the lack of

sanitation.

22

WHO 2012 23

According to CDC 2010 – Center for Disease Control and Prevention – dengue has emerged as a worldwide problem only since the 1950s. As many as 100 million people are infected yearly worldwide. The Pan-American Health Organization (PAHO/WHO) relates greater incidence of dengue and its expansion to regions not affected before to the global warming effect.

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With this scenario the Ministry of Health created the Program for

Eradication of Dengue24 in 1996.25

The appearance of a new serotype (dengue 3) in Brazil in late 1990s,

which in the period of only three months spread to eight states made it clear that

there was a high risk of a new epidemic of dengue fever (DF) and dengue

hemorrhagic fever (DHF).

It has been a major health/sanitation related problem since then.26 This

alarming fact led to the intensification of governmental actions to combat the

dengue in 2002 through formal/specific nationwide federal programs, a task force

among federal, state and municipal authorities which proved to be quite effective,

reducing the incidence of dengue by 73% during the first six months of 2004.27

Nevertheless, it reached new epidemic levels in first quarter of 2013 (635

thousand cases/108 deaths in only 3 months) with an increase of 279% in

comparison to same period in 201228.

24

Programa de Erradicacao do Aedes Aegypti – PEAa 25

Among its findings were the fact that dengue could be solved only on a mid/long term basis. Only in 1995 the reporting of dengue infections became mandatory in Brazil. 26

Brazil’s Ministry of Health 2002 – Epidemic Surveillance 27

In 2002 the Ministry of Health created the PNCD – Programa Nacional de Controle da Dengue (National Program for the Control of Dengue). Further on (2003) and within the PNCD, it created and coordinated the National Mobilization Program against the Dengue with the participation of 40 representative departments, agencies and organizations in the country. Incidence was reduced by 73% from the first six months of 2003 to the same period in 2004 – down from 300 thousand to 84 thousand people infected nationally. Brazil’s Ministry of Health issued an epidemic alert due to the dramatic increase of reported cases of dengue fever in the first quarter of 2013 where it registered an increase of 279% in comparison to same period in 2012. In a period of only three months from Jan-Mar 2013, 635.161 cases were registered, among which 1.243 were considered serious with 108 deaths caused by dengue haemorrhagic fever.

28 See supra note 24 – Ministry of Health – Evolution of dengue in Brazil - cases/year

Number of Cases (x 1000)

75 135 386 696 275 70 147 259 497 633 406 1.011 764 591

Deaths DHF

1 3 41 121 52 8 37 78 148 259 174 300 191 104

Year 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

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Number of Cases of Dengue Fever in Brazil

Number of Deaths caused by Dengue Haemorrhagic Fever in Brazil

0

200

400

600

800

1000

1200

2000200220042006200820102012

Cases (1000)

0

50

100

150

200

250

300

350

19

99

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

20

08

20

09

20

10

20

11

20

12

Deaths

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Legal Framework – Brazil

Sanitation is a theme addressed in Brazil’s Constitutional Reform of

1988. The constitution establishes how water and sanitation must be handled by

the three spheres of power – federal, state and municipal. It also determines that

all water resources including rivers, lakes and water basins are property of the

Brazilian State.

The principle of autonomy of the 26 different States and the capital

Brasilia, and that of distribution of powers are part of the essence of Brazil’s

constitutional pillars. The nature of these powers is political-administrative

(president/ governors/ mayors) and legislative (federal, state, municipality).

The constitution determines that all three spheres of power have the

political and administrative obligation to manage and control public health, to

protect the environment and control any and all forms of pollution (art. 23). Art. 241

establishes that the three levels of power must apply the entirety principle to the

administration of public services:

Art. 241 The three spheres of power shall discipline via legislation

the public partnerships and the partnerships of cooperation among

the three levels, authorizing joint-administration of public services

as well as total or partial transfer of responsibilities, services,

personnel and assets which are essential to the continuity of

services transferred.

Nonetheless, the specific matter of legislation regarding water systems,

sanitation, environmental protection and pollution control is under exclusive federal

jurisdiction. It must be noted that sanitation is inserted under the broader context

of Water Systems, art. 22 IV of the constitution, and that legislation related to the

use of waters, criteria to be adopted and priorities for its use are of sole federal

responsibility.

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As determined by its art 21 XIX, federal law (Nr. 9433 of 1997) created

the Brazilian System for the Management of Water Systems29 and the National

Department of Waters – (L9984/2000)30.

Art. 21 XX prescribes that definition of directives for urban development,

including housing, sanitation and urban transportation, is also under federal

jurisdiction.

It is the responsibility of Congress and the President to provide

legislation establishing the rules that govern the area of Sanitation in Brazil.

Federal law 11445 (2007) stipulates the national sanitation directives as well as

federal sanitation policies. Public services related to sanitation need to comply with

the following fundamental principles:

Universality of access

Health and environmental safety

Efficiency and sustainability

Social participation

Safety, quality and regularity

Integration of sanitation infrastructure and services with the

efficient management of water sources

Brazil’s constitution determines that water resources are not part of the

public sanitation services. The use of water resources in public sanitary services,

including sewage collection, transportation and treatment, is subject to the federal

concession of right of use, regulations and state legislations in accordance to

federal law (L9433/97).

As a result of Brazil’s continental size (world’s 5th largest, closely

following Canada, China, US with Russia being an isolated 1st) with near 200

million people (also 5th)31 to be serviced, as well as the number of states and

municipalities involved in the sanitation and water supply systems, there is a

multiplicity of principals and agents involved in the complete process.

In observance to federal statute, Brazil employs a mixed system for the

operation of the sanitation services and stimulates cooperation among federal,

state and municipal levels. The result is a complex and gigantic network which

includes the 26 states, the capital and over 5570 municipalities.

29

Sistema Nacional de Gerenciamento de Recursos Hidricos 30

Agencia Nacional de Aguas – ANA (Ministry of Environment) 31

The World Bank 2012

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As prescribed by law, in principle it is the responsibility of the

municipality to operate the sanitation system as a whole, with the exception of

water supply, which includes waste disposal, transportation and treatment, and all

interrelated services (control, public health, environment, and others) as well as

planning, construction and management of all necessary infrastructures.

In many cases such as the State of Sao Paulo, the system is operated

by a mixed capital corporation (SABESP) dully licensed to perform the sanitation

and water supply services in the greater metropolitan area of its capital (the city of

Sao Paulo) and other municipalities which together consist of a total of 365

municipalities in the state. It is the larger and most efficient sanitation and water

company in Brazil, providing32:

100% of treated water to 27.7 million people

Sewage collection to 90% of the area under its responsibility

Sewage treatment to 88% of the area covered

In number of customers (27.7 million), it is among the largest

sanitation companies in the world – it provides services to 67.2%

of the population of the whole Sao Paulo State (41.2 million

people), corresponding to almost twice the population of

Belgium. The Sao Paulo metropolitan area alone has a

population of 20 million people (Shanghai has approximately 23

million people; Beijing – 20 million; Mumbai – 18.4 million)

Number of employees – 14,896

Municipalities serviced – 365, which include the large

metropolitan area of the city of Sao Paulo (Sao Paulo state total

– 645)

Since 2002 its shares are listed in the Sao Paulo and New York

stock exchanges

New horizons – in addition to the State of Sao Paulo, it is now

ready to expand its activities to other states and countries

It is important to observe that SABESP does not operate in slums

(favelas) because of legal, technical, operating and environmental constraints33.

The number of people that live in what is officially classified as overcrowded

32

SABESP – Companhia de Saneamento Básico do Estado de São Paulo 33

Legal – no legal title of land (informal settlements), pathways do not exist for legal purposes / Technical-operating-logistics – narrow and winding (many times steep) alleys of difficult or no viable access; drug dealing and crime poses an additional problem / Environmental – many dwellings located in environmental sensitive areas (pollution, landslides, floods)

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subnormal poverty concentrations in the Sao Paulo metropolitan area totals 2.2

million34.

Conclusions of Case Analysis

Brazil is a nation of contrasts, that carries the stigma of inequality which

places the country still far from fulfilling the right to dignity of millions of its citizens:

rich/poor, rich country/poor people, world’s 6th largest economy/85th ranking in

United Nation’s Human Development Index (HDI). It has a long-standing,

structurally poor social legacy of inequality and poverty with its origin in political-

administrative inefficiencies and corruption, with enormous health, environmental,

educational, socioeconomic and welfare hurdles to overcome.

In the area of sanitation Brazil has made significant progress in the last

decades and still has a long way to go as it ranks 9th in number of people without

toilets at home.35 It has a good legal framework to support the initiatives needed in

its route to universalization of the access to sanitation by its 200 million people.

Nevertheless, Brazil will not solve this problem of gigantic, ever growing, atypical

and unimaginable proportions with typical initiatives – solution necessarily goes

through political resolve and unconventional methods and efforts of the equal

dimension of the problem.

Most important is the fact that there is greater awareness and

involvement in the part of the society in a clear demonstration that it wants

concrete advances in these interconnected social, civil and human rights’ areas.

34

IBGE - 2010 Demographic Census (Brazilian Institute of Geography and Statistics) 35

WHO 2012