EDITORIAL
The urban legend of hospitalizations due to lack of sanitation in Brazil
"In Brazil, 68% of hospital admissions are due to lack of sanitation." Such claims are widely flaunted in reports, scientific publications, and legal texts. The weight of sanitary conditions on the health system is obviously overestimated in this case, considering that the principal cause for hospital admissions in Brazil is childbirth, fortunately. According to the excellent DATASUS website, based on the database for the Unified National Health System (http://www.datasus.gov.br), in the year 2004, causes related to childbirth and the puerperium accounted for 23.0% of hospital admissions, followed by diseases of the circulatory and respiratory systems. Infectious and parasitic diseases appear as the fourth cause of hospitalization, accounting for 8.4% of the total. If one considers only the diseases traditionally classified as waterborne, this proportion drops to 4.8%.
An Internet search using principal fragments from the introductory sentence, such as "lack of sanitation" and "% of hospitalizations" produces more than five hundred links to web pages of various institutions and organizations with similar contents. The statement's repetition turns it into a veritable urban legend when one examines the pattern by which the purported information spreads: its alarming content, the impreciseness or total lack of quoted sources, the lack of specification of the place or reference period, and the claim's systematic reproduction. As a strategy to combat urban myths and legends, one might ask what is being classified as hospitalization due to lack of sanitation and even what is being referred to as lack of sanitation.
The so-called "sanitation-related diseases" include such diverse maladies as dengue, leptospirosis, hepatitis A, ascaridiasis, and others, which display different transmission modes. A desirable characteristic of an epidemiological indicator is that it identifies risks that can be measured and that are amenable to intervention. To lump data under the broad framework of "sanitation-related diseases" does not contribute either to the identification of problems or to intervention in their determinants. It is also unfortunate that such false information is still circulated in Brazil after years of efforts to improve the Health Information Systems, to disseminate data from the Unified National Health System, and to construct and standardize indicators through initiatives like the Inter-Agency Health Data Network (RIPSA).
In addition, the majority of the Brazilian urban population has been acquiring access to running water and sewage systems. This may well mean that today's sanitation problems in Brazil are of a different kind, such as sewage treatment, garbage disposal, and protection of headwaters. In the large Brazilian cities, the vast majority of households are connected to the water supply system, but this alone does not guarantee the quality of the water supply.
Sanitation in the cities and countryside remains a priority in Brazil. Sanitation is a citizen's right, a comfort item, a safety factor, and a health guarantee for the population. In order for this right to be fully realized, it does not suffice to install the systems; the water supply must be guaranteed in sufficient quantity and quality for consumption. And the development of adequate epidemiological indicators is crucial for monitoring this service.
Christovam Barcellos
Departamento de Informações em Saúde, Centro de Informação Científica
e Tecnológica, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil.
xris@cict.fiocruz.br