BMC Public Health. 2015 Feb 27;15:191. doi: 10.1186/s12889-015-1534-7.
Diarrhea and health inequity among Indigenous children in Brazil: results from the First National Survey of Indigenous People’s Health and Nutrition.
Escobar AL, Coimbra CE Jr, Welch JR, Horta BL, Santos RV, Cardoso AM.
Background: Globally, diarrhea is the second leading cause of death among children under five. In Brazil, mortality due to diarrhea underwent a significant reduction in recent decades principally due to expansion of the primary healthcare network, use of oral rehydration therapy, reduced child undernutrition, and improved access to safe drinking water. The First National Survey of Indigenous People’s Health and Nutrition in Brazil, conducted in 2008-2009, was the first survey based on a nationwide representative sample to study the prevalence of diarrhea and associated factors among Indigenous children in the country.
Methods: The survey assessed the health and nutritional status of Indigenous children < 5 years of age based on a representative sample of major Brazilian geopolitical regions. A stratified probabilistic sampling was carried out for Indigenous villages. Within villages, children < 5 years of age in sampled households were included in the study. Interviews were based on a seven day recall period. Prevalence rates of acute diarrhea were calculated for independent variables and hierarchical multivariable analyses were conducted to assess associations.
Results: Information on diarrhea was obtained for 5,828 children (95.1% of the total sample). The overall prevalence of diarrhea was 23.5%. Regional differences were observed, with the highest rate being in the North (38.1%). Higher risk of diarrhea was observed among younger children and those who had less maternal schooling, lower household socioeconomic status, undernutrition (weight-for-age deficit), presence of another child with diarrhea in the household, and occurrence of upper respiratory infection.
Conclusions: According to results of the First National Survey of Indigenous People’s Health and Nutrition, almost a quarter of Indigenous children throughout the country had diarrhea during the previous week. This prevalence is substantially higher than that documented in 2006 for Brazilian children < 5 years generally (9.4%). Due to its exceedingly multicausal nature, the set of associated variables that remained associated with child diarrhea in the final multivariable model provide an excellent reflection of the diverse social and health inequities faced by Indigenous peoples in contemporary Brazil.
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I believe this article confuses “access” with “quality”. Access can certainly be opened or closed by government through laws and force. Water quality cannot. Government can impose rules and regulations on people and impose hardships on economies and citizens. But the contaminants in drinking water sources really do not care what government does. Pulling levers of government and society (e.g. taking a Marxist approach to “governing” water quality) by imposing laws and regulations may or may not result in improved water quality. [But it will certainly cause hardship.]
Georgia L. Kayser, Urooj Amjad, Fernanda Dalcanale, Jamie Bartram, Margaret E. Bentley. Drinking water quality governance: A comparative case study of Brazil, Ecuador, and Malawi Environmental Science and Policy April 2015 48:186-195
Human health is greatly affected by inadequate access to sufficient and safe drinking water, especially in low and middle-income countries. Drinking water governance improvements may be one way to better drinking water quality. Over the past decade, many projects and international organizations have been dedicated to water governance; however, water governance in the drinking water sector is understudied and how to improve water governance remains unclear. We analyze drinking water governance challenges in three countries – Brazil, Ecuador, and Malawi – as perceived by government, service providers, and civil society organizations. A mixed methods approach was used: a clustering model was used for country selection and qualitative semi-structured interviews were used with direct observation in data collection. The clustering model integrated political, economic, social and environmental variables that impact water sector performance, to group countries. Brazil, Ecuador and Malawi were selected with the model so as to represent the diversity of the clusters. This comparative case study is important because similar challenges are identified in the drinking water sectors of each country; while, the countries represent diverse socio-economic and political contexts, and the case selection process provides generalizability to our results. We find that access to safe water could be improved if certain water governance challenges were addressed: coordination and data sharing between ministries that deal with drinking water services; monitoring and enforcement of water quality laws; and sufficient technical capacity to improve administrative and technical management of water services at the local level. From an analysis of our field research, we also developed a conceptual framework that identifies policy levers that could be used to influence governance of drinking water quality on national and sub-national levels, and the relationships between these levers.
This type of study is done every once and awhile and is intended prop up fluoridation to show that dental flourosis is not really that bad after all. Cosmetic effects of fluoride (mottling of teeth) can occur in a portion of the population even at low fluoride levels in drinking water. Well, do the cosmetic effects from fluoride in drinking water negatively affect a child’s well being? That child will become an adult. Will it matter then?
Further, this and other studies typically infer that because the investigators did not find a problem using a particular statistical test that there is no problem. Such an inference is based certain assumptions that are not stated but are commonly assumed. It is simply not possible to prove a negative finding.
Moimaz SA, Saliba O, Marques LB, Garbin CA, Saliba NA. Dental fluorosis and its influence on children’s life. Braz Oral Res. 2015;29(1):1-7. doi: 10.1590/1807-3107BOR-2015.vol29.0014.
This study verified the prevalence of dental fluorosis in 12-year-old children and its association with different fluoride levels in the public water supply, and evaluated the level of perception of dental fluorosis by the studied children. To assess fluorosis prevalence, clinical examinations were performed and a structured instrument was used to evaluate the self-perception of fluorosis. The water supply source in the children’s area of residence since birth was used as the study criterion. In total, 496 children were included in the study. Fluorosis was diagnosed in 292 (58.9%) children; from these, 220 (44.4%) children were diagnosed with very mild fluorosis, 59 (11.9%) with mild fluorosis, 12 (2.4%) with moderate fluorosis, and 1 (0.2%) child with severe fluorosis. A significant association (p = 0.0004) was observed between the presence of fluorosis and areas with excessive fluoride in the water supply. Among the 292 children that showed fluorosis, 40% perceived the presence of spots in their teeth. The prevalence of fluorosis was slightly high, and the mildest levels were the most frequently observed. Although most of the children showed fluorosis to various degrees, the majority did not perceive these spots, suggesting that this alteration did not affect their quality of life.
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This study raises a number of important issues. The underlying philosophy of this particular publication promotes one particular point of view.
de Barcellos AP. Sanitation Rights, Public Law Litigation, and Inequality: A Case Study from Brazil. Health and Human Rights. 2014 Dec 11;16(2):E35-E46.
Public law litigation has been used in many places to advance human rights related to health. In Brazil, such lawsuits usually request that the government pay for pharmaceuticals to individuals. But could litigation play a role in shaping public health policies to benefit communities? To explore this question, this paper focuses on lawsuits involving determinants of health, namely water and sanitation public policies. This paper discusses the results of an empirical study of 258 Brazilian court orders, issued in a 10-year period, that address requests for sewage collection and treatment. The data show that the Brazilian judiciary is willing to improve access to sanitation services. However, litigation has addressed fewer than 177 out of the 2,495 Brazilian municipalities that lack both sewage collection and treatment systems, and lawsuits are concentrated in the richer cities, not in the poorest ones. This paper suggests that public law litigation can be used to foster public health policies similar to the way in which structural reform litigation and the experimentalism approach between courts and defendants have influenced public policies and achieved institutional reform in schools and prisons. However, greater effort is needed to target initiatives that would reach the most disenfranchised communities.
Marcynuk PB, Flint JA, Sargeant JM, Jones-Bitton A, Brito AM, Luna CF, Szilassy E, Thomas MK, Lapa TM, Perez E, Costa AM. Comparison of the burden of diarrhoeal illness among individuals with and without household cisterns in northeast Brazil. BMC Infect Dis. 2013 Feb 4;13:65. doi: 10.1186/1471-2334-13-65.
BACKGROUND: Lack of access to safe and secure water is an international issue recognized by the United Nations. To address this problem, the One Million Cisterns Project was initiated in 2001 in Brazil’s semi-arid region to provide a sustainable source of water to households. The objectives of this study were to determine the 30-day period prevalence of diarrhoea in individuals with and without cisterns and determine symptomology, duration of illness and type of health care sought among those with diarrhoea. A subgroup analysis was also conducted among children less than five years old.
METHODS: A face-to-face survey was conducted between August 20th and September 20th, 2007 in the Agreste Central Region of Pernambuco State, Brazil. Households with and without a cistern that had at least one child under the age of five years were selected using systematic convenient sampling. Differences in health outcomes between groups were assessed using Pearson’s Chi-squared and two-way t-tests. Demographic variables were tested for univariable associations with diarrhoea using logistic regression with random effects. P-values of 0.05 or less were considered statistically significant.
RESULTS: A total of 3679 people from 774 households were included in the analysis (1863 people from 377 households with cisterns and 1816 people from 397 households without cisterns). People from households with a cistern had a significantly lower 30-day period prevalence of diarrhoea (prevalence = 11.0%; 95% CI 9.5-12.4) than people from households without a cistern (prevalence = 18.2%; 95% CI 16.4-20.0). This significant difference was also found in a subgroup analysis of children under five years old; those children with a cistern had a 30-day period prevalence of 15.6% (95% CI 12.3-18.9) versus 26.7% (95% CI 22.8-30.6) in children without a cistern. There were no significant differences between those people with and without cisterns in terms of the types of symptoms, duration of illness and health care sought for diarrhoea.
CONCLUSIONS: Our results indicate that the use of cisterns for drinking water is associated with a decreased occurrence of diarrhoea in this study population. Further research accounting for additional risk factors and preventative factors should be conducted.
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Nascimento HA, Ferreira JM, Granville-Garcia AF, Costa EM, Cavalcante AL, Sampaio FC. Estimation of toothpaste fluoride intake in preschool children. Braz Dent J. 2013;24(2). pii: S0103-64402013000200142. doi: 10.1590/0103-6440201302087.
The objective of this study was to estimate the intake of toothpaste fluoride used by children aged 2 to 6 years (n=87) treated at a hospital of a medium-sized city (Campina Grande, PB) in the Northeastern region of Brazil. Data regarding sociodemographic characteristics of families and children’s toothbrushing were collected from questionnaire-based interviews with parents/guardians, and the amount of fluoride used during toothbrushing was estimated using a precision scale for assessment of the risk of dental fluorosis, considering a cutoff value of 0.07 mgF/kg body weight/day. Fluoride content in the toothpastes was analyzed using a specific fluoride electrode. Data were analyzed using descriptive and inferential statistics using the chi-square and Fisher’s exact tests (α=0.05). Considering the use of the derice, the risk of fluorosis in the children was 19.5%. There was significant association (p<0.05) between the risk of fluorosis, brushing frequency, type of derice and who performed the child’s oral hygiene. It was concluded that a high percentage of children in the studied sample used toothpaste inappropriately and were at risk of developing dental fluorosis.
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In this study samples were taken and tested for fluoride in Brazilian cities. The results of these analyses are presented, and then the statement is made:
“cities performing fluoridation had fluoride levels within the range that provides the best combination of risks and benefits, minimizing the risk of dental fluorosis while preventing dental caries.”
No evidence is provided that the above statement is true in the population served. The conclusion is imposed on the data by the authors.
Moimaz SA, Saliba NA, Saliba O, Sumida DH, Souza NP, Chiba FY, Garbin CA. Water fluoridation in 40 Brazilian cities: 7 year analysis. J Appl Oral Sci. 2013;21(1):13-9.
Objectives Fluoride levels in the public water supplies of 40 Brazilian cities were analyzed and classified on the basis of risk/benefit balance. Material and Methods Samples were collected monthly over a seven-year period from three sites for each water supply source. The samples were analyzed in duplicate in the laboratory of the Center for Research in Public Health – UNESP using an ion analyzer coupled to a fluoride-specific electrode. Results A total of 19,533 samples were analyzed, of which 18,847 were artificially fluoridated and 686 were not artificially fluoridated. In samples from cities performing water fluoridation, 51.57% (n=9,720) had fluoride levels in the range of 0.55 to 0.84 mg F/L; 30.53% (n=5,754) were below 0.55 mg F/L and 17.90% (n=3,373) were above 0.84 mg F/L (maximum concentration=6.96 mg F/L). Most of the cities performing fluoridation that had a majority of samples with fluoride levels above the recommended parameter had deep wells and more than one source of water supply. There was some variability in the fluoride levels of samples from the same site and between collection sites in the same city. Conclusions The majority of samples from cities performing fluoridation had fluoride levels within the range that provides the best combination of risks and benefits, minimizing the risk of dental fluorosis while preventing dental caries. The conduction of studies about water distribution systems is suggested in cities with high natural fluoride concentrations in order to optimize the use of natural fluoride for fluoridation costs and avoid the risk of dental fluorosis.