A Political Ecology of Wellbeing: The role of civil society organizations in supporting communities with limited access to water, sanitation, and hygiene in Brazil

Abstract

Safe access to water, sanitation, and hygiene (WASH) is key to human health and wellbeing. When populations lack or have limited access to WASH, they are at risk of contracting infectious diseases, suffering dehydration and malnutrition, developing musculoskeletal diseases, experiencing gender-based violence and conflict, and facing challenges to access other social determinants of health, such as health care and education. Regardless, billions of people lack access to safe WASH globally, mainly in low- and lower-middle income countries (LMICs). Nonetheless, historically marginalized groups in high income countries (HICs) and upper-middle income countries (UMICs) still face challenges to access WASH despite available financial and natural resources. In Brazil, the country with the largest supply of freshwater water and the 9th biggest economy in the world, 32 million people lack access to safe water and 89 million, to safe sanitation. The COVID-19 pandemic shone a spotlight on the role of civil society organizations (CSOs) in creating and implementing solutions to access WASH as a way to halt the spread of the disease and offer relief aid to low-income communities that had their livelihoods affected by lockdowns and social distancing measures. Among other initiatives, CSOs around the world donated water and hand sanitizers, constructed communal wells and portable handwashing stations, and raised awareness about proper hygiene habits. Nevertheless, little is known about the way these organizations address WASH inequities, especially in UMICs, and how they support health equity-promoting practices in general. The overall purpose of this research is to examine the role of civil society organizations in promoting solutions to water, sanitation, and hygiene inequities in Brazil. The specific research objectives are: 1) to describe barriers and facilitators in access to water, sanitation, and hygiene in low-income communities in Brazil, 2) to explore the impacts of water, sanitation, and hygiene inequities on the wellbeing of low-income communities in Brazil through political ecology of health, and 3) to investigate solutions to water, sanitation, and hygiene inequities implemented by civil society organizations in low-income communities in Brazil. Using an integrated knowledge translation (IKT) approach to research and informed by political ecology of health, I conducted a multisite case study in three municipalities in the Metropolitan Region of Rio de Janeiro (MRRJ), whose populations experience varying levels of access to WASH and support from CSOs. I interviewed leaders from local CSOs (n = 7) and led focus groups with residents of low-income communities (n = 24) in each municipality. Additionally, I visited the headquarters of partner CSOs, a local water treatment station, other affected communities, and attended meetings with local municipal governments. Interviews and focus groups were recorded and transcribed verbatim, translated from Portuguese to English, and analyzed through thematic analysis on NVivo. The results revealed common barriers in access to WASH in all communities, including frequent and long-lasting water shortages, contaminated drinking water, absence of sewage collection and treatment, and complications from severe weather events. WASH inequities affect several dimensions of participants’ wellbeing but most importantly, emotional health and sense of dignity, as they compared their living conditions to that of residents in other neighbourhoods as a consequence of persisting structural inequities. Finally, solutions to WASH inequities differ according to the level of resources and expertise offered by partner CSOs, revealing geographical inequities in access to funding and manpower between organizations located in the state capital and those in peripheral municipalities. This research makes contributions to the political ecology of health framework by proposing a political ecology of wellbeing through the contextual understanding of “wellbeing” and how WASH access affects low-income communities beyond physical and mental health. Additionally, this research advances the understanding of the complex role of local CSOs as intermediaries between decisionmakers, academics, and marginalized communities, capable of communicating the needs and wants of populations in a concise and representative manner and facilitating both short- and long-term equity-promoting action. Finally, this research contributes to the body of work on WASH inequities in HICs and UMICs, advancing the notion that certain marginalized populations are rendered invisible by global WASH data that ignores nuanced local inequities, such as the frequency and quality of WASH services. In conclusion, CSOs in Brazil promote short-term infrastructural WASH solutions, promote critically reflective dialogue about the distribution of environmental and social determinants of health and wellbeing, and act as intermediaries between powerful actors who decide what happens in the territory, e.g., local politicians, criminal groups, and WASH companies. CSO work can be scaled up if responsible authorities recognize their role as knowledge brokers and design policies considering context-specific needs and challenges for each community, while also supporting civil society organizations’ services to promote autonomy and agency among marginalized groups in the long term.