Perspectives in Health Magazine
The Magazine of the Pan American Health Organization
Volume 8, Number 1, 2003
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Perspectives in Health Magazine |
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 The shantytown of Glicério, beneath a highway overpass in central São Paulo, presents a host of environmental hazards. They increase the risks of accidental injuries, poisoning, respiratory problems and vector-borne diseases in children.. (All photos ©Alexandre Spatuzza) |
"Jonathan is terrible," his 22-year-old mother Rute chimes in. "He gets these rashes and doesn’t stop scratching them, so they get all red." Jonathan lives in a three-room brick shack with his mother and three siblings, Jessica, 8, Luiz, 4, and Milena, 3. The children share a tiny windowlessbedroom with a bare-mattress bed, a wardrobe and a handful of toys.
According to Rute, they are normally healthy except for occasional fevers she attributes to the wild temperature fluctuations in São Paulo’s subtropical climate. It’s not uncommon for a daytime high of 30 degrees Celsius (86° F) to be followed by a rainy 15 degrees (59° F) at night.
"When he was younger, he had water in his lungs," says Rute of Jonathan. "But he is all right now with this weather." Jonathan is luckier than his sister Jessica. In her short life she has suffered a collapsed lung, the beginnings of pneumonia, bronchitis and appendicitis, her mother says. On this hot summer afternoon, Jessica is at school, a good 2-kilometer uphill walk through heavy traffic from her house. She seems healthy enough for now, says her mother.
"It’s destiny," says Rute. "I don’t think living conditions have anything to do with it. You can live in a good neighborhood and have health problems too."
The dos Santoses live in São Paulo’s downtown neighborhood of Vale do Anhangabaú, in a compound of six houses. Residents share a central yard strewn with rubble and crisscrossed by clotheslines that droop under the weight of wet laundry. The families get their running water and electricity through illegal tapping. Dirty water from washing and showers runs through the middle of the yard, while the toilets empty into a covered ditch. There are 13 children living in the compound (and three more to be born this year). They share their living and play spaces with rats (fewer now that poison was put out) and abundant cockroaches and mosquitoes. All this is within sight of São Paulo’s City Hall.
Jonathan’s compound is an example of the environmental risks that millions of children in Brazil and throughout the Americas are exposed to every day. The lack of access to treated water and sewage disposal and the presence of vermin are primarily the result of chronic poverty and haphazard urban development. Though Jonathan’s mother sees no connection, experts say environmental conditions like these contribute to an estimated 5 million childhood deaths worldwide every year.
 Young residents of Glicério clown for a reporter's camera. |
The lack of play space, formal leisure activities and often even access to schooling exposes poor children to another set of environmental risks. Accidents such as falls, traffic accidents, electrocution and suffocation kill an estimated 100,000 children annually in Brazil alone, according to the Brazilian church group Pastoral da Criança. Poverty also increases children’s exposure to violence, including stray bullets, domestic abuse and homicide.
These problems can be particularly acute in cities. "Children mostly play in the streets, because they have nowhere else to go," says Katia Edmundo of the Center for Health Promotion (CEDAPS), a nongovernmental organization based in Rio de Janeiro. "There are also cases of children being locked in their houses all day because the parents are afraid of the violence on the streets but have to go to work and can’t afford day care."
There are signs that the situation has improved in some ways in the last decade. Sanitation coverage in the region rose from 66 percent of the population in 1990 to 79 percent in 2000, while potable water coverage rose from 80 percent to 85 percent during the same period, according to the Pan American Center for Sanitary Engineering and Environmental Sciences (CEPIS), a technical center of the Pan American Health Organization (PAHO). These improvements have contributed to declines in both infant (under age 1) mortality and child (under age 5) mortality throughout the region in the last decade.
Brazil is one of the countries that have seen the biggest reductions. Its child mortality rate dropped from 64 per 1,000 live births in 1994 to 45.2 per 1,000 in 1999. (By comparison, Colombia reached a relatively low rate of 34 deaths per 1,000 in 1999 but started with 42 per 1,000 in 1994.) One of the main reasons for the improvements in Brazil has been increased access to clean drinking water, along with health promotion initiatives first introduced in 1991 and significantly stepped up in the last seven years. An increase in school enrollment also has helped.
But there is still a long way to go. "About 20 percent of the urban population has 21st-century living standards, but the rest are heavily impacted by the environment they live in," says Ivan Estribi, a PAHO consultant in Brazil and expert on environmental health.
"In cities, people have easier access to drinking water, which goes a long way in reducing deaths from preventable diseases. But they live in unhealthy houses, exposed to dangers such as factories and pollution, and at risk from landslides because of the areas they live in."
In rural Brazil, an estimated 20 million people, or about 12 percent of the population, are considered out of reach of government programs.
"There is no official information about how these people live, where they get their water from," says Estribi.
In the past, large-scale government programs were viewed widely as the only way to address such problems. But these have gone only so far in getting children out of danger zones. Chronic financial woes have made it difficult for federal, state and local governments to detect communities’ problems, let alone solve them.
Tito Nery, a pneumologist in the São Paulo Mayor’s Office, offers the following analysis: According to the city government, about 2 million people live in shacks or substandard housing in the city’s favelas, or shantytowns. At last count, there were more than 2,000 favelas. If the local government were to begin diagnosing problems and implementing solutions at the rate of one community per month it would take more than 150 years to reach the whole city. For Nery, further improvements can be reached only through community mobilization.
 Residents of Jardim Paraná, on São Paulo's northern outskirts, organized and obtained potable water and sanitation services from the city government. Improving their children's health was a major motivation. |
"Canu," a 23-year-old soccer enthusiast, bounds off the field where he has been helping out with the tournament. The 6-foot-tall right-midfielder’s real name is Jose Nilton Adelino Pereira. He confides to a visitor that he is waiting for the most important news of his life: whether he will get a professional contract with a soccer team in the state of Santa Catarina or with the club his manager is negotiating with in the town of Guaratinguetá in São Paulo state.
The improvised soccer field also serves as the main venue for community meetings, Pereira explains. More important, it is where the municipal government will soon build a $3.8 million educational project that includes a kindergarten, an elementary school (it will be the neighborhood’s third school), cultural and sports centers, and a community space known as CEU, an acronym for Unified Educational Center that in Portuguese also means "heaven."
"It will be good because it will take a lot of the kids off the streets, and that is just what they need," says Pereira.
Pereira speaks of children’s needs with the authority of recently acquired adulthood and its responsibilities. He lives with his sister, and together they pay about $25 a month for their 60- square-meter lot. They also pay for running water and electricity. When a new sewage drainage system is completed, as expected in the near future, they will also pay for and benefit from that.
But Jardim Paraná has not always been the community it is now.
"I arrived here when I was 16, and violence was rife," Pereira recalls. "Besides the drug trafficking gangs there were petty crooks and lots of fighting over land, since community leaders tried to stop new settlements. At the time, one of my friends got killed in a bar robbery because the girl carrying out the robbery fired by accident. I kept out of trouble because I always make friends with everybody."
He also remembers long trips to health centers and hospitals and long waits to get treatment. His main ailments were the flu and stomach aches. Bad conditions did not help, he says: "At the time we had to filter the muddy water and boil it to drink, but I know a lot of people didn’t do it," he says.
Jardim Paraná’s transformation was difficult but did not take long. The community came into being in the early 1990s, when rising rents and lack of housing options prompted some 180 settlers to invade what was at the time privately owned land. In 1995, a court eviction order forced the occupiers to organize, and in the end they and hundreds of other followers purchased the land for just over $570,000 to be paid over 10 years. With legalization came the possibility of improving living conditions.
"The eviction notice was the last straw; ever since then we have organized ourselves," says Antonio Calisto, a bus driver and community leader.
A second turning point in the neighborhood’s history came in 2000, when a child and an adult died of hepatitis after drinking sewage-contaminated water. The deaths prompted demands to the state government for potable water and sewage collection. In October 2001, after several months of protests and negotiations, the whole neighborhood received treated water and a rudimentary sewage collection system from the state sanitation company. Now the community is negotiating a storm drainage system and the installation of a medical post, and is raising funds to build a kindergarten run by the community center, Calisto says.
 Residents of Jardim Paraná, in São Paulo, Brazil. |
"There are some families that still don't have access to treated water so we’re trying to get the water company to extend the network," says Calisto, who serves as president of the residents’ association.
"The conditions there [in Jardim Paraná] are far from perfect, but at the beginning the situation was so dire that I was surprised not to find typhus in the region," says Thelma Nery, a pediatrician and founder of the nongovernmental National Health Organization, which has helped the Jardim Paraná community organize itself and fight for environmental improvements using a strategy known as Primary Environmental Care, promoted by PAHO.
The successful community organizing has led to "green" environmental initiatives as well. Jardim Paraná borders an Atlantic forest preservation area known as Serra da Cantareira, and some 45,000 square meters of the land purchased by the community lies within the forest’s boundaries. The community is seeking partnerships with private organizations to protect and manage the forest and preserve it for their children’s future.
Jardim Paraná’s organizing has had other benefits, too. It has attracted the attention of the Rotary Club, which plans to build a community center focusing on small business development as a way to create jobs.
Health and environmental initiatives must be developed alongside programs that create income and redistribute wealth in poor regions, says Marcia Westphal, head researcher at CEPEDOC, a University of São Paulo research center on "healthy cities."
"You have to think of biomaps and include in the planning not only health and environment but also housing and the economy," she says. "If the houses are substandard and people in the region don’t have a job, then you don’t produce social health, you produce social illness. You have to coordinate activities in different sectors."
Using the healthy cities concept as a basis, Westphal develops strategies to empower local communities. The process starts with rallying community members around a cause and teaching them to diagnose their problems and define priorities. Once the local communities are aware of the problems they can start working with local governments and private entities to improve basic services.
Katia Edmundo, of CEDAPS, has seen this process in the Rio de Janeiro district of Vila Paciencia, where her organization has a health promotion and community empowerment program. There, community members determined that the main source of a common skin disease in children was their direct contact with pigs that wandered freely in the neighborhood feeding on rubbish. Eventually the pigs were confined, and the skin problems began to diminish.
"The health of children is by far the main motivator for community organization," says Edmundo. "Once the diagnosis is made, people can start to take action."
That assumes one important additional detail: that communities are somehow "legalized." In many poor neighborhoods, residents lack property titles because they "invaded" the land or it was sold to them illegally, or in some cases because they cannot pay for the necessary paperwork. In the absence of official documents, government agencies find it difficult to arrange to provide basic services.
Jardim Paraná is a case of a community that mobilized, legalized and began to construct a better future for its children.
Meanwhile, in Vale do Anhangabaú, Jonathan dos Santos continues to build mud castles 200 meters from City Hall while his 50-year-old grandmother looks on. When a visitor asks her who owns the land, she answers: "I’ve been here for 15 years and am still trying to get the property rights in court."
Alexandre Spatuzza is a Brazilian freelance journalist living in São Paulo.
