Water and Health: past, present and perspectives

Water and Health: past, present and perspectives

By María Alejandra Silva

March 22 is a celebration designated by the UN since 1993, which makes it possible to reflect on the fact that almost two-thirds of the world's population does not have access to quality water. In this case, the purpose is to reflect on the issue from the medico-social perspective and motivate all health workers to act.

Since the history of medicine, the importance of water in the conservation of collective health has been observed. In this sense, historical writings indicate that its provision was linked to the role of the State as guarantor of the public hygiene service.

The purpose of this writing is to reflect on the link between water and health at a time when the role of the retreating state leaves the provision of public services such as water to private interests as if it were just another commodity. Water is essential for the existence of life on our planet; in such a way that man needs it for his biological survival, as a basic element in the composition and functions of the human organism, as well as the fact of being the vehicle par excellence of pathogens, but because water is a constitutive part of an entire chain that for a long time has kept the physical, chemical and biological balances that guarantee the renewal of natural resources that have become indispensable for the life of man in society both in the countryside and in the city.

However, this writing starts from the social history of medicine to culminate with the analysis of the contemporary problems that the population suffers daily.

The importance given to water from the medical point of view is clearly related to the vision of collective health, which has its historical roots in Europe, led by Thomas Rauss, Richman and Frank.

In the first place, Rauss and Richman in 1764 elaborate a code of medical police that includes governmental programs to preserve: the well-being of the earth and the population, protection against infectious diseases, tobacco and beverages, food inspection and water, cleaning and drainage of cities, the existence of health councils in local administrative offices, etc. Later, J.P. Frank studies the health problems of children (hygiene, physical culture, nutrition and recreation), accidents, communicable diseases and proposes legislation for the parturient. These ideas spread through Hungary, Italy, Denmark and Russia. In England in the 18th century the ideas of N. Grew concur. And J. Bellens and W. Petty. The latter highlights the need to study occupational groups of interest to the State. (Aldereguía Henríquez, 1985).

Medicine and social hygiene were born in the 19th century, both terms being used synonymously and did not identify adverse positions, where the French Revolution had a powerful impact in theory and practice through L. Sinke, L. Villermé and Rochoux . Villermé with his study in 1840 of the sanitary conditions of a textile factory, generated a movement in 1841, which ended in the labor law on childhood.

It carries out mortality studies in different sectors of the country that show the relationship between the following aspects: poverty and disease, income and physical development, work occupation and tuberculosis, etc. (Aldereguía Henríquez, 1985)

This vision of health comes to Germany from Neuman and Virchow. The latter studies the cholera epidemic in Silesia during 1847 and identifies as its causes, in addition to the biological and physical, the economic, social and political. For cholera, he highlights the role played by water in the spread of the disease. Virchow is the main exponent of social medicine and social epidemiology, which is the area that addresses the distribution and the determinants of health states, in its most consensual sense. It differs from the clinical approach of the individual case since the mid-nineteenth century, based on a discrepancy on the definition of "cause". This ideological confrontation allowed the consolidation of two currents of Epidemiology and Medicine. The first current sees disease as a biological phenomenon and medicine as a biological science, where the agent plays the main role. Here, the disease may have a single cause (unicausality) or risk factors (multiple associated factors) that together favor the onset of the disease. It is strengthened by the studies of Koch, it becomes hegemonic and is known as Medicine and Epidemiology. The second sees medicine as a social science and the causes of disease as social causes, the result of the social structure and the social process. The concept of social causality of the disease means that the proposed therapy had as its objectives the social structure and the work process, which provokes resistance, since it implied changes in the status quo. Its main theoretician is R. Virschow and is known as Social Medicine and Social Epidemiology. (Carneiro Miranda, 1995)

In England they support social medicine: J.P. Kay, Tunner Trackrah and Rumsey. On the one hand, Kay studies in 1832 the conditions of a cotton factory in Manchester and the health of the workers; on the other hand Trackrah carried out studies of occupational health in 1831 and in 1856 Ramsey formulated the principles of a social policy for health care in his essays on state medicine. The consolidation of social medicine culminated in Germany with Alfred Grotjahn who published his book "Social Pathology" in 1911.

These different approaches to the problem of collective health were emerging as social and political changes occurred that produced modifications in the ways of falling ill and dying. In this sense, Tomas Mc Keown indicates in the Introduction to Social Medicine that: “in the agricultural economies of the Middle Ages, problems related to the large population, poor hygiene and insufficient food were combined. Cholera spreads when water-supplied towns are created, and malaria becomes severe as population size and the opportunity to create vectors increased with advances in agricultural techniques. The spread of intestinal infections (typhoid, dysentery, TB, salmonella, etc.) was the result of contamination of food and water. On the contrary, industrialization shows that the causes of the decrease in infections are associated with changes in economic and social conditions. (Module of Medicine and Society, 2000).

It is important to highlight the importance of social impact measures such as the distribution of quality water, before changes in individual behaviors, since it is known that such guidelines were scarce in the 18th century and improved in the middle of the 19th century. So emphasis was placed on the root of the problem: the infected source of unpurified water, which in turn aided in food hygiene. This is why Mac Keown claims that typhoid fever and its spread were due to faulty facilities, while the rapid reduction in mortality during the last third of the 19th century can be attributed to specific measures, particularly the safe water supply introduced then. (Module of Medicine and Society, 2000).

In the next topic, mention is made of the social history of medicine in the


2. Water and health in Argentina: traces of the past

The social outlook on health is heterogeneous depending on the European influence. The three currents that influence Argentine ideas are: State medicine, urban medicine, and workforce medicine.

In Germany state medicine emerged, focused on the improvement of state public health or called "medical police", in the middle of the seventeenth century. It is concerned about the health of the individuals who make up the State and are faced with economic and political conflicts with neighboring countries.

On the other hand, at the end of the 18th century, urban medicine emerged, concerned about urbanization that generated economic and political problems, and about subsistence riots where silos, markets and granaries were looted. The objectives were: 1) To study the places of accumulation of waste in the urban space that could spread diseases and epidemics (cemeteries and slaughterhouses), b) to analyze the areas of overcrowding, disorder and danger in the city, c) control and distribution of things and elements: especially water and air [1]. In 1742, the first hydrographic plan was built, accompanied by urban planners who indicated the best ventilation methods for cities, houses, and streets. It is cataloged as the medicine of the living conditions of the environment.

Thirdly, in England it arises from the problems derived from poverty at the end of the 19th century that make it a political problem (the agitations of the poor transform them into a political force), social (due to popular disturbances) and health (the cholera epidemic of 1832 that arose in Paris and spread throughout Europe). Three significant health measures are established: a) dividing the urban area into sectors of the poor and the rich, b) subjecting the indigent to periodic medical checks, as well as vaccination, which makes them more suitable for work and less dangerous for wealthy sectors of society, c) organization of the epidemic registry and mandatory declaration of dangerous epidemics,). Location of unsanitary places and destruction of these foci (Foucault, 2000)

Before 1870, the task of an exponent of this group of intellectuals stands out, Marcos Sastre, a teacher who collaborated with General Urquiza in Entre Ríos and held the position of Inspector of Primary Schools in 1850. He was the one who designed the class benches o "school law firms" that spread throughout the country, under the prevailing hygienist idea in his vision. Sastre points out: Many of the details of a school demand the energetic action of the hygienist, none is more important than the desk for what directly interests the child. The school desk is precisely one of the main factors in the various conditions that children contract at school. With the child leaning forward, his head and eyes are next to the book, a position that congests the brain and helps determine myopia. In addition, one shoulder constantly raised due to the defect of the table, becomes and remains higher than the other, the chest sinks and the functions of breathing and circulation suffer from the vicious and prolonged position " (Evocative Historical Museum, “Justo José de Urquiza” School, 2004)

Other important statements in Argentine history come from the educator Domingo Faustino Sarmiento (1811-1888), who points out: “The first thing that must be attended to throughout the country is to provide the largest and least well-off class with the means to meet their first needs. and particularly those that have a direct influence on hygiene and health ”.

Regarding the doctors who contribute from this integral vision of health, it is worth highlighting the task of Guillermo Rawson (1821-1890), who indicates: “Knowing that many diseases are curable, insofar as their determining causes are known and can be suppressed, it is the first step and falls under the domain of science. The will and the necessary means for the removal of these causes, corresponds to the people to supply them through their municipal or political organization ”(Passarini, 2002).

In general, the doctors of the time formed the so-called hygienism, which as Susana Murillo affirms “carried the idea of ​​controlling the social environment, so that life was more rational and therefore healthier (both in a physical and moral sense) ...

From here it is articulated with the role of the legislator, the jurist, the criminologist, the social reformer, the psychologist and the psychiatrist ”. This current of thought spread in Argentina from the UBA School of Medicine, expands to all social policies between 1871 and 1913, which have antecedents in 1822 and are reflected in "the scientific precautionary plan" dating from 1852. This is Observe in a review of the history of the country that shows the creation of different governmental and social entities aimed at achieving this objective.

During these years the layout of parks and avenues, the construction of airy houses for the poor, developing various branches such as: dietary, moral, social and health police. In 1875 an ordinance was created to organize the exercise of brothels and a regulation of conventillos was issued. Between 1880 and 1891 sanitation works were carried out, the sweeping machine was incorporated to clean the streets, the National Department of Hygiene (DNH) was also created during 1880 in charge of the surveillance of houses, public buildings, industries, ports and railways . In 1893 the Regulation of Health Inspectors was enacted to monitor health in ports and in 1894 the position of Factory and Industrial Hygiene Inspector was created, allowing them to access workplaces. (Murillo, 2000).

In this historical context, the work of Juan Bialet Massé stands out, who brings together interdiscipline to address the relationships between health and work, due to his knowledge of medicine, law and architecture. It alludes to working and health conditions in the early 1900s, whose ideas are found in the "Report on the state of the Argentine working classes at the beginning of the 20th century" dating from 1904. It includes the need to provide good water conditions to workers to conserve productive workforce.

The first mention is made in volume I when he observes the working conditions of a construction company in Jujuy: "In La Calera, a little more than 1 km from the river bank, you can see the camp where all the hygiene, malaria and typhus rules ... there is no water filter in the entire camp: the effect of so much filth, so much insects and discomfort is that not a single one of those who lives in that center has escaped malaria ... robust and young men full of life, in four months they have become sickly types, without meat, without strength, or color ... "

The second allusion is found in volume II when he visits the mines of Upulungos and says: "There at the age of 40 the miner is exhausted and old, because in that dry atmosphere the evaporation is rapid and gives irresistible thirst. I myself have verified it being a water drinker I felt dry, my tongue stuck to my palate and I asked for water. They bring me a glass with a liquid filled with gray-looking suspended mineral molecules… I try to swallow it but I can't, it has a frankly poisonous arsenical metallic taste. I ask if there is no other water and they tell me NO, I can only protest because that is inhuman, people are being murdered.

The third reference also arises from volume II when it relates the working conditions of the seamstresses of Córdoba and comments: On this site, ordinary sewing is the worst pay in the republic. The tenement houses of the city are atrocious and that is where the seamstress works, because the civilized latrine has not entered Cordoba. The pieces have impossible floors, they are dirty until disgusting, girls and expensive. The consequence is forced: Córdoba is the city that has the highest mortality rate from infectious diseases in the republic. There you have to ask which microbes are missing, because of the exceptions, apart from cholera, yellow fever and bubonic, I have no news. Municipal action is void, all taxes go to salaries and penalties if enough to sweep, light, schools and water (CEAL, 1984).

A few years later, in 1907, a social event is recorded that involves a claim for better living conditions and availability of water at a cost that the population can bear: the tenant strike that arises in Buenos Aires and expands to Córdoba, Rosario and Bahía Blanca. The slogans of the strike were: 1) non-payment of rents until they are lowered by 30%, 2) achieve sanitary improvements in the tenements, 3) eliminate the three months of deposits and, 4) that the owners do not retaliate with the participants in it.

This event occurs because the affected population agreed to live in overcrowded conditions because during that time the predominant housing characteristics were those, added to the high rental costs, affecting workers in general and home workers: seamstresses, ironers , assemblers and tailors.

In the 1980s there were around 2,000 tenements with 100,000 inhabitants, where overcrowding and lack of hygiene were alarming. In 1904 the municipal census of Bs. As. Indicates that 22% of the tenements did not have bathrooms (showers and latrines) of any kind.

In terms of health, a major political fact stands out: the yellow fever epidemic of 1871 that devastates Bs. Causing the death of 10% of its total population and almost 50% of the inhabitants of tenements. (Suriano, 1983).

The journalists covered the events and indicated that the situation in the tenements was due to criminal greed (La Prensa, April 10, 1871) and the Municipal Council recommends certain conditions of habitability (type of materials, doors, floors, latrines, place garbage, etc.), where the latrine and the drain are separated from the rest of the pieces and are washed daily.

Suriano demonstrates the active participation of doctors of the time such as Rawson, Coni and Palacios.

On the one hand, Guillermo Rawson bluntly declares: “the worker returns home in search of a restful sleep after having spent the energy of his muscles, but instead of rest he finds that each inspiration reaches his lungs, his blood , to his brain and to all the organs the latent poison suspended in the impure air ... The same happens to his wife ... who happens to swell the number of population or unfortunate gentlemen who live to suffer and who do not reach any rest than that of death."

On the other hand, the doctor and deputy Alfredo Palacios presents a bill that prohibits the establishment of water meters in the tenements because it is an unfair measure that does not apply to the rest of the houses. Palacios emphasizes that it was also declared unfair by another doctor, Dr. Emilio Coni, appointed by the director of the sanitation works to make a comparative study of the different water distribution systems.

This deputy uses arguments from medicine to argue the bill, and warns that the lack of personal hygiene, food, clothing and housing due to the lack of water produces numerous infectious diseases. While the material progress of the city exists, the workers live in miserable rooms, where several generations of tuberculosis have been born and died, and from where Argentines will come out incapable of pulling the plow, working in the workshop, fulfilling their compulsory military service, and will be a contingent with physical impossibility that will go to nursing homes and hospitals.

Palacios indicates: “Forcing tenants to pay a supplementary fee of ten cents per cubic meter is unfair because the worker needs more water than the rest of the population for his work and housing, since he has few clothes and must wash them frequently in the same room, and for his family (he lacks the resources to entrust the washing to someone else). Also in times of hot summer, when the exodus of the wealthy classes to the spas is observed, he must remain in the capital. He concludes: “it is explained that a water meter should be installed in stables, in large gardens, in factories, in distilleries, but from no point of view it can be admitted the convenience of establishing meters in the houses of the poor . (Suriano, 1983)

In those same years, Torcuato de Alvear affirms that it is necessary to achieve the construction of model tenements where speculators build more houses and latrines and water must be used, not only because they are more comfortable and cheaper, but also more hygienic. Presents a project that never got the political support to materialize [2]. Two other recognized doctors in Argentine history who have a social vision of health where living conditions and access to water are a fundamental aspect are Ramón Carrillo and Carlos Alvarado.

The first affirms: "Health does not constitute an end in itself, for the individual, or for society, but a condition of full life, and it is not possible to live fully if work is a burden, if the house is a cave and if health is one more benefit of the worker. " … "Faced with the diseases that misery generates, facing sadness, anguish and the social misfortune of the peoples, microbes, as causes of disease, are poor causes Ramón Carrillo (1906-1956)

The second declares: “Basic actions in health with useful coverage, with the participation of the countrymen and residents who will be health agents, with simple methodologies, house by house and child by child, where people live and work laboriously, like bees, with effort and commitment to the people, with what we have at hand, on foot and by bicycle, the slogan is to get there, where the problems are ... And part of all this must show that we have eliminated or reduced the damage. "Carlos Alvarado, Jump, 1978.

Argentina participates in a world event that proposes a change in the outlook on health, indicating modifications outside the health system that effectively impact the morbidity and mortality profile, as the case that brings us together in this article. We refer to September 12, 1978 in Alma Ata, Republic of Kazakhstan, where the International Conference on Primary Health Care took place, jointly sponsored by the World Health Organization, WHO, and the United Nations Fund for Health. Childhood, UNICEF. There, the representatives of 134 nations approved a transcendent declaration in which all governments, health and development agents and the world community are urged to adopt urgent measures to promote and protect the health of all citizens. It was agreed that some of the world's most serious health problems could be addressed through simple prevention methods, such as the implementation of the PHC primary health care strategy.

The Primary Health Care strategy recognizes that its success depends on the active participation of the community and the collaboration between the different sectors of society.

In the Alma ATA document, WHO identifies three main goals for health for all:

* Promotion of lifestyles directed towards health.

* Prevention of diseases.

* Health care service establishments.

On the topic of promoting health-oriented lifestyles, it is indicated that it should be based on several pillars, one of which is: “the intersectoral approach both from the government and from all the institutions that have influence to improve social conditions. and economic that affect the choice of lifestyle.

This document talks about the prevention of diseases, which will be achieved with several activities, among which it is mentioned: "The drinking water supply network should be increased, as well as other sanitation measures" (Ministerio De Salud De La Province of Santa Fe, 2004).

Although ALMA ATA thought of "health for all in the year 2000", this instance was reached with typical diseases of the middle age, as well as numerous problems of accessibility, coverage, cost, etc. In this context of deficiencies, in 2000 numerous social organizations, including from Argentina, met in Bangladesh (India) to reflect on the advances and setbacks since 1978. They sign the "DECLARATION FOR THE HEALTH OF THE PEOPLES", they indicate that Health is a social, economic, and political issue, and above all it is a fundamental human right. Inequality, poverty, exploitation, violence and injustice are at the root of poor health and the deaths of the poor and marginalized. They indicate that health is a reflection of the commitment of a society to have equity and justice, with the broader determinants of it being: economic challenges, social and political challenges, environmental challenges, war, violence and conflict.

In this document, the problem of water appears again as one of the environmental challenges that determine health conditions. Among the environmental challenges it is indicated: "Water and air pollution, abrupt climate change, depletion of the ozone layer, nuclear energy and waste, toxic chemicals and pesticides, loss of biodiversity, deforestation and soil erosion have extensive health consequences. The causal roots of this destruction include the unsustainable exploitation of natural resources, the absence of a long-term holistic vision, the diffusion of individualistic behaviors and profit maximization, and over-consumption by the wealthy.

This destruction has to be faced and reversed immediately and effectively ”.

Also the I International Forum in Defense of Peoples' Health in 2002, held in Brazil, refers to water in a broader framework, and indicates:

"Health is an integral process that goes through decent living conditions, healthy employment in adequate conditions, access to basic services such as quality water, education to develop citizenship, adequate food, a healthy environment, without violence and health care services. accessible and quality health at all levels ”.

From all the aforementioned it is observed that it is evident that the water problem that worried doctors so much in the 1800 and early 1900s continues.

But why in 2006 we have to be arguing about the same thing that worried Rawson, Coni, Palacios and Bialet Massé in Argentina?

In the next paragraph some answers are outlined.

3. Water and health: a major economic problem?

But they already stole a lot of water from us, when they dismounted, when they populated with pines and eucalyptus trees, on the Litoral and beyond. And of soy, transgenic and forage, in the Humid Pampa and beyond, etc. etc. We see it clearly in Misiones, where water courses and reserves have decreased by less than half and many times disappeared,

in recent years, and to the same extent as the growth of eucalyptus and pine plantations.

... If we do not stop the theft of water, we will not continue life ...

Juan Yahdjian, 2006

Understanding the problem of water from a health perspective implies starting by reflecting on the root of the problem. Does the impact on the health of the population that lack water or those who are victims of floods only respond to the designs of nature? Or is it a problem of a political nature?

Similar reflections arose in 2004 about the Tsunami, such as

the report entitled “Reducing the risk of disasters”, published on February 2,

2004 by the United Nations Development Program (UNDP), which asks

whether to continue talking about "natural" catastrophes like the Tsunami. Always according to the UNDP, "on a planetary scale, there is a lack of about 80,000 million dollars per year to ensure all basic services", that is, access to clean water, shelter, decent food, primary education and essential health care. (Ramonet, 2004).

Similar data are released in Johannesburg (South Africa), when the World Summit on Sustainable Development is held and it is stated: “there are 1,200 million people in developing countries who do not have access to safe drinking water and 2,200 who do not have sanitation. basic. The shortage of clean water causes hygiene problems and diseases ”.

However, the particularity that water assumes as a precious commodity for life and production ends up generating political conflicts between cities and nations for access and control. After World War II, between the years 1948 to 2002, 1,831 interactions caused by water were recorded, of which 1,228 were cooperative in nature that ended in the signing of 200 water distribution treaties and the construction of new dams. There were also 507 conflicts, of which 37 were violent, 21 with military interventions and 30 have been carried out by Israel and its neighbors. However, everything seems to indicate that the incorporation of good water as an economic resource will be the detonator of the greatest conflicts in the world during the 21st century. Ismail Serageldin, Vice President of the World Bank, expressed it by stating that “the next World War will be over water” (Rothfeder, 2001).

This problem which is expressed as a political conflict is actually explained for other reasons. The demand for drinking water is growing for several reasons: population increase; greater concentration of the rural population in urban areas (currently more than half of the world's population is concentrated in cities) caused by free trade agreements, poverty and lack of support for the countryside; increased privatization of land and the consequent expulsion of indigenous and rural populations; construction of infrastructure (roads, airports, aqueducts, oil pipelines, dry channels, dams, etc.) that necessarily imply the same expulsion; greater contamination of rivers and aquifers and wells by industry; intensive use of agrochemicals; GMO plantations that demand more agrochemicals and large tracts of monocultures for agro-export; y el incremento de la producción minera extractiva, entre otras consecuencias. Esta demanda de agua potable hace cada vez más atractivo el negocio de la creación de infraestructura privada y del consumo de agua embotellada (Castro Soto, 2006)

Por eso aquellos que realizan proyecciones futuras indican que los problemas crecerán, agravados por la consideración del agua como una mercancía más. Incluso predicen conflictos numerosos entre los que se destacan:

* Entre poblaciones rurales y urbanas. Se han registrado guerras y conflictos de diversa índole en Israel, Jordania, Siria, Palestina, Egipto, Yemen, Irak, Kuwait.

The United States also disputes water from Mexico and does so on the Triple Border with Argentina, Uruguay and Paraguay. There are also conflicts in the Aral Sea, Jordan, Nile and Tigris-Euphrates basins.

* Entre los sectores agrícola, industrial y doméstico. Agriculture consumes 67%; the industry uses 20% (the equivalent to all the world hydroelectric production); y los usos municipales y domésticos un 10% (Castro Soto, 2006). En se marco numerosos estudiosos del tema se preguntan: ¿acaso el problema permanece irresuelto porque hay quienes buscan beneficiarse económicamente de dicha carencia ofreciendo algún tipo de agua embotellada o bebida substituta? En caso afirmativo: ¿cuál es el rol del Estado?, y ¿Cómo resolverán este problema los grupos sociales postergados de cada país? Esta ausencia del Estado en la puja de intereses por el acceso y el control del agua en Argentina hoy: ¿termina favoreciendo a los detentadores de mayor poder como lo hacia a principio del siglo pasado? ¿Qué rol le cabe a la ciudadanía ante este conflicto de intereses? Con motivo de ahondar en la cuestión local, en el párrafo siguiente se alude a la Región Centro de la Argentina: Santa Fe y Córdoba.

4. Agua y salud: el caso de la región centro.

En el año 2000 el FMI otorgó los préstamos a 12 países bajo la condición de privatizar del agua. Entre ellos estaban Angola, Benin, Guinea-Bissau, Honduras, Nicaragua, Nigeria, Panamá, Rwanda, Senegal, Tanzania, Yemen y Sao Tomé y Príncipe . La misma condición impuso el BM entre 1990 y 1995 al conceder 21 préstamos que aumentaron a más de 60 entre 1996 y 2002 con un fondo de 20 mil millones de dólares para proyectos de agua. En este tiempo México, El Salvador, Honduras, Argentina y Bolivia entre otros países viven diversos procesos y niveles profundos de privatización del agua (Castro Soto, 2006).

En ese contexto la provincia de Santa Fe participa del proceso de privatización. En la provincia de Santa Fe, desde diciembre de 1995 toma posesión Aguas Provinciales de Santa Fe y se instala en 15 localidades: Rafaela, Esperanza, Rosario, Santa Fe, Reconquista, San Lorenzo, Granadero Baigorria, Villa Gdor Gálvez, Rufino, cañada de Gómez, Funes, Firmat, Cap. Bermúdez, Casilda. No obstante, según datos de la ADS, de 3.150.000 habitantes, existe un total de 1.500.000 que tiene problemas con el agua (accesibilidad geográfica, económica, o problemas de contaminación).

Asimismo, geográficamente existe una disparidad de base entre la zona oeste (con problemas de contaminación con Arsénico (Firmat, Funes, Villa Cañas, etc.), pero en otros casos se relaciona con el ente encargado de la distribución y venta (cooperativa de agua potable, municipio o comuna). No obstante cabe resaltar que existe el Sistema de Potabilizaron de Agua rural, dependiente del gobierno de la provincia, cuyo objetivo es controlar estos aspectos del agua que se vinculan directamente con la salud. Según datos de la ADS, los problemas del agua se correlacionan con los brotes de diarrea, hepatitis y gastroenteritis [3].

Es preocupante que todavía existan zonas que utilicen agua con una concentración de arsénico superior al máximo compatible con la potabilidad de las mismas, ya que puede generar trastornos progresivos cutáneos, alteraciones circulatorias cardiacas y del aparato circulatorio periférico. Mas aun cuando ha sido difundido un estudio epidemiológico en la región con diferentes tipos de cáncer.

Hay un estudio epidemiológico sobre la frecuencia relativa de los diferentes tipos de cáncer hallados en la zona endémica afectada por alta concentración de arsénico inorgánico en el agua de consumo (sur, centro y este de la provincia de córdoba, chaco, San Luis, Santa Fe y La Pampa). En la región centro, el mismo abarco las zonas de Venado Tuerto (Sta. Fe), Río cuarto, Bell Ville, Marcos Juárez y San Francisco (Córdoba). Allí todas las localizaciones viscerales de las “neoplasias arsenicales descriptas por diferentes autores están por arriba de las tasas esperadas.

Las más frecuentes localizaciones del cáncer fue la piel, con una proporción del 16,42%. Se comprobó una alta incidencia de cáncer de la mucosa vesical, uréter y uretra, así como un ligero exceso sobre las cifras de incidencia media del país en las neoplasias malignas de mucosa oral, lengua, esófago y tracto gastrointestinal (Astolfi, E y otros, 1982).

Más recientemente también se diagnosticó un problema similar en otra zona de Santa Fe: el departamento Castellanos. En ese caso, la ciudad de Ramona, una población de 2.000 habitantes, fue protagonista de un estudio de vinculación entre agua y salud [4].De 1981 hasta 1996 existen registros de enfermedades de la piel significativos, que se acompañan con la presencia de sintomatología de HACER en 1998 y con una mortalidad por cáncer de gran importancia epidemiológica entre 1978 y 1999 (sobre 298 personas fallecidas, se produjeron 96 muertes por cáncer- el 30%).

En dicho caso se toman como referencia aquellos estudios del Ministerio de Salud de la provincia de Córdoba en 1997, que demostraron la vinculación entre la presencia de arsénico en agua y el índice promedio de mortalidad por 7 tipos de cáncer (pulmón, próstata, colon y vejiga, riñón, laringe y piel).

No obstante en la actualidad existen métodos de tratamiento para reducir el arsénico presente en agua, como los siguientes: osmosis inversa, coagulación/filtración, alúmina activada, intercambio iónico, nanofiltración, filtro de agua anti-arsénico. No obstante, se escuchan argumentos que indican su alto costo y complicado uso y mantenimiento, ante lo cual surge el interrogantes ¿por qué seguimos sin realizar cambios en esta situación, cuando en realidad ya el medico Bialet Massé lo había señalado en 1904? ¿Es posible seguir diciendo que desde 1904 hasta la fecha nunca tuvimos recursos económicos o voluntad política para realizar cambios?, ¿Qué estuvieron haciendo los médicos y trabajadores de la salud que no promovieron acciones desde la sociedad civil, en pleno ejercicio de la ciudadanía? En fin, son muchos interrogantes y pocas respuestas.

El problema del agua no termina en Santa Fe, aunque haya cambiado de manos la empresa que presta el servicio, pues desde hace unos meses es el estado quien se hizo cargo del mismo en esas 15 localidades. Un caso puntual es el de la ciudad de Rosario, receptora de migrantes sin trabajo, que alberga a la mayor cantidad de población de la provincia. La misma se encuentra afectada en numerosos barrios que no tienen agua o solo pueden acceder a ella en escasa cantidad, lo cual puede constatarse en el verano del 2005 y se reitera el verano del 2006.

Otra región afectada por el problema del agua es Córdoba. Allí integrantes de la Asociación de Pequeños Productores del Norte Cordobés (APENOC) indican que:

“Hoy el Estado no tiene políticas sociales para el campo con las que pueda garantizar desde la distribución del agua hasta el crédito o subsidio a los pequeños productores para que puedan seguir existiendo, produciendo y manteniendo a sus familias en el campo. Se sigue adelante con este modelo: los desmontes, la concentración de la tierra y la expulsión de poseedores”. Belén Agnelli, de Apenoc, relata: “En una zona donde estás preparado culturalmente para producir agricultura, al sacarte uno de los recursos importantes como es el agua, te inhabilitan para hacer lo que siempre supiste hacer. Distinto es en la zona de secano donde nunca llegó el riego, hay cultura de ganadería, hay otra forma de producir y otra relación con el agua a partir de eso.

Pero en las zonas que siempre han basado su producción en el doble recurso, la tierra y el agua, sacándoles ese recurso los obligaron prácticamente a dejar de ser productores, a dejar de ser campesinos” (Segura, 2006).

Cabe destacar que el sector rural tiene características particulares, porque si bien se parte de problemas de accesibilidad de larga data, también se ve perjudicado por el predominio del modelo sojero impuesto en la década de los 90 (monocultivo de soja trasngénica a gran escala) [5] que corre las fronteras agropecuarias y avanza sobre las pequeñas unidades productivas. Los problemas de abastecimiento de agua en las zonas rurales incluyen desde la inequidad en la distribución del agua de riego que favorece a los grandes productores hasta la contaminación y la falta de agua porque no se realizan las obras de infraestructura necesarias para obtenerla. Esta situación se agrava con el avance de la frontera agrícola con concentración de tierras (y agua), desmontes y perforaciones (Segura, 2006).

Por tal razón, en algunas organizaciones del sector rural, como la Federación Agraria Argentina (FAA) y Agricultores Federados Argentinos (AFA), se ha colocado el tema del agua dentro de la agenda de discusión durante el 2005.

Ambas jurisdicciones dan cuenta de la magnitud del problema, por lo que cabe reflexionar: ¿Por qué hay que seguir repitiendo las denuncias hechas por médicos sanitaristas argentinos de hace 100 años atrás?, ¿estamos igual que hace 100 años?, O acaso estemos peor, pues los avances tecnológicos, médicos, en la infraestructura no se reflejan en mejores condiciones de vida de la población, y todavía existen “ciudadanos de segunda”.

Por eso en el tópico siguiente se hacen algunas reflexiones, a partir de las nociones de ciudadanía.

5. Algunas reflexiones: en busca de la ciudadanía perdida.

Aunque, se reconoce el importante papel del agua para la preservación de la salud, es en realidad poco lo que se ha avanzado, quizá porque de lo que se trata es de llevar a cabo medidas que involucren a los diferentes ámbitos en los que el ser humano participa como un ser económico, político y cultural, de tal forma que en tanto no se logren plantear medidas coordinadas, la salud de la población seguirá siendo seriamente afectada por padecimientos que en el consumo colectivo de agua contaminada encuentran el origen epidémico de afecciones que técnicamente son conocidas y controladas por los avances de la medicina: se conoce al virus, la bacteria o el parásito que las identifica; asimismo, se han determinado las medidas y acciones epidemiológicas a seguir, y sin embargo es una realidad el que, en todos aquellos países situados fuera del llamado desarrollo, sea una alta proporción de la población que enferma y muere por infecciones y parasitosis, en las que el suministro, la disponibilidad y la calidad del agua juegan un papel determinante. El agua es indispensable para llevar a cabo procesos de lavado y desinfección de alimentos, así como de higiene personal, y de espacios familiares y comunitarios que tienden a constituirse en reservorios de virus, bacterias, parásitos; que encuentran allí las condiciones propicias para reproducirse, alcanzando su expresión social en términos de enfermedad y de muerte. Los virus, las bacterias, los parásitos, solo infectan y/o infestan a una población, cuando existen las condiciones que facilitan su contagio y propagación. (González González y Gaytán Olmedo, 2001).

Por tal motivo es preciso retomar los conceptos vertidos en el Foro Mundial Alternativo del Agua, que en su tercera versión de marzo del 2005 reafirma: El derecho al agua como derecho humano, el estatuto del agua como bien común, el financiamiento colectivo del acceso al agua y la gestión democrática del agua en todos los niveles.

Estos principios fueron retomados este año en las Jornadas en Defensa del Agua en contra del 4to Foro Mundial del Agua realizado en México, que son una respuesta “ante la preocupante situación que viven millones de personas en el mundo que no tienen acceso seguro al agua ni al saneamiento, donde los cuerpos de agua contaminada envenenan a nuestras comunidades y ecosistemas, en que organismos internacionales y empresas transnacionales promueven privatizar los servicios de agua y saneamiento, en el contexto del interese en las ganancias por encima de la justicia y los derechos humanos, es urgente que la sociedad civil denuncie y trabaje por cambiar esta situación.

También en el V Foro Social Mundial llevado a cabo en enero de 2005 se lanzo la plataforma Global de Lucha por el Agua, refrendando el líquido como un derecho humano y un recurso público….enfatizando la prioridad en los grupos más débiles…

En conclusión, todos estos encuentros internacionales, así como la historia social de la medicina coinciden en señalar que el agua es uno de los pilares de la salud, que debe ser defendido en diferentes instancias de debate público. Esto requiere de médicos, trabajadores de la salud, profesores-investigadores comprometidos con la tarea, ejerciendo activamente sus derechos como ciudadano.

En esa senda, cabe reflexionar sobre el concepto de “ciudadanía”. Marshall sostiene que la ciudadanía consiste en asegurar que cada uno sea tratado como un miembro pleno de una sociedad de iguales. De esta forma, la manera de asegurar ese tipo de pertenencia es otorgar a los individuos un creciente número de derechos de ciudadanía. Divide a estos derechos en tres categorías que se fueron incorporando en forma sucesiva entre el siglo XVIII y el XXI.

En el Siglo XVIII se incorporan los derechos cívicos: libertad de persona, libertad de expresión, de pensamiento, de confesión, derecho a la propiedad y a concertar contratos, derecho a la justicia. Estos derechos son administrados por los Tribunales de Justicia. En segundo lugar, en el Siglo XIX se incorporan los derechos políticos: derecho a participar en el ejercicio del poder político y ser elector. Son derechos garantizados por los parlamentos. Por último; en el Siglo XX se incorporan los derechos sociales: derecho a un mínimo de bienestar y seguridad económica, derecho a participar en el patrimonio social, a vivir la vida de un ser civilizado de acuerdo a los patrones vigentes en una sociedad determinada; derecho a la educación pública, a la asistencia sanitaria, a los seguro de desempleo, a la pensiones de vejez.

Estos derechos se institucionalizan en el Estado de bienestar (Silva, 1999) La ciudadanía estuvo prisionera del ámbito estatal y fue puesta en cuestión tanto en Europa como en Argentina con:

• La crisis del Estado de Bienestar y el recorte de las políticas proteccionistas;

• La disociación social causada por la precarización del trabajo;

• La marginación de la esfera pública liberal que muestra un marcado escepticismo hacia la vida política (Quiroga, 1998).

Esta concepción juridicista; que tiene su raíz en el pensamiento de Marshall; suele ser criticada en virtud de su naturaleza “pasiva” o “privada”, porque no supone la obligación de participar en la vida privada, asumir responsabilidades y ejercer determinadas virtudes ciudadanas donde se incluye la autosuficiencia económica (Kymlyka y norman, 1997).

Esta denominación polémica es una constante en la historia. Desde la Revolución Francesa predomina el problema derivado de la concordancia entre “un derecho” y “un comportamiento”; esto es entre el principio de solidaridad (la sociedad tiene una deuda para con sus miembros) con el principio de responsabilidad (cada individuo es dueño de su existencia y debe hacerse cargo de si mismo) (Rosanvallon, 1995).

Otros analistas, como Kymlyka y Norman, declaran que el nudo está en la confusión entre dos conceptos: la ciudadanía legal (la plena pertenencia a una comunidad política) y la ciudadanía como actividad deseable; según la cual la extensión de la ciudadanía depende de la participación de los sujetos en su comunidad.

En suma, la Argentina se encuentra en ese dilema: esperar que el Estado le otorgue el derecho al agua o de manera activa, reclamar por obtenerlo a través de diferentes organizaciones sociales. Dilusidar el camino adecuado para la concreción del derecho al agua, le cabe un rol distintivo a los trabajadores de la salud.

6. Bibliografia consultada

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Porto Alegre – Brasil, del 29 al 30 de enero.

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Astolfi, E y otros (1982), Hidroarsenicismo crónico regional endémico, Cap. Epidemiología descriptiva del cáncer en la región afectada por hidroarcenicismo crónico regional endémico (frecuencia relativa), buenos Aires.

Carneiro Miranda, P. (1995). Los apellidos de la epidemiología: pasado, presente y futuro, En: Rev. de la Escuela de Salud Pública, Córdoba, Argentina, Vol. 6, nro. one.

Castro Soto, Gustavo (2006). El andamiaje para la privatización del agua, Ecoportal, Web site:

CEAL (1984), Informe Bialet Massé sobre el estado de las clases obreras argentinas a comienzos del siglo, Buenos Aires.

Declaración para la salud de los pueblos (2000), Bangladesh, India.

Foucault M. Nacimiento de la medicina social (2000), En M. Foucault. Estrategias de poder, .Barcelona: Paidós Básica. [Editado en 1977 en la Revista Centroamericana de

Ciencias de la Salud].

González González, Norma y Ma. Soledad Gaytán Olmedo (2001), Salud y medio ambiente. Escasez y calidad del agua, su impacto en la problemática sanitaria, ponencia presentada en el XXIII Congreso de la asociación latinoamericana de sociología (ALAS), realizado en la Sede Universidad de San Carlos de Guatemala, del

29 de octubre al 2 de noviembre.

Jornadas en Defensa del Agua en contra del 4to Foro Mundial del Agua (2006), México, web site: ; y/content/view/full/56626.

Publicada el 20 de febrero de 2006.

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Buenos Aires.

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Medicas/UNR, Rosario.

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pp. 51-63. Web site:

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Declaración De Alma Ata , Dirección De Promoción Y Protección De La Salud,

Departamento De Educación Para La Salud.

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1871/1913, En: A. Domínguez Mon, A. Federico, L. Findling y A. María Méndez Diz,

La salud en crisis”, Ed. Dunken, Buenos Aires.

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Estado. Mesa Central del 15 de Noviembre 2002, XVII Congreso Nacional y IV

Internacional de Medicina General y XI del Equipo de Salud, organizado por la

Federación Argentina de Medicina General-Familiar, San Luis, 14, 15, 16 Y 17 de noviembre.

PIERNAVIEJA, Cesar (2006), Un Día Internacional para recordarnos la importancia del agua, Publicado el 17 de marzo, CIOSL/ORIT, web site :

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(cap. 1); Buenos Aires.

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Concepción, Concepción, Chile, 12 al 16 de octubre Suriano, Juan (1983), La huelga de inquilinos de 907, historia testimonial Argentina, Centro Editor de América Latina, Buenos aires.

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22 de marzo de 2006.

_ Lic. en Ciencia Política/UNR, Magister en Sociología/FLACSO, Prof. Facultad de Ciencias

Medicas/UNR de la Materias “Medicina y Sociedad” en las electivas “Historia social de la Medicina” y

“Enfermedades emergentes y re-emergentes”

[1] Era la época de la teoría miasmática que indicaba que el aire influía directamente sobre el organismo porque transportaba miasma, o porque su excesiva frialdad, calor, sequedad, humedad se trasmitían al organismo.

[2] Dicha huelga culmina luego de la muerte de un trabajador baulero italiano de 18 años de edad llamado Miguel Pepe que genera mayor represión policial, reflote de la ley de residencia y deportación de los extranjeros.

[3] Faccendini, Aníbal, Abogado y Presidente de la Asamblea por los Derechos Sociales (ADS), Rosario, entrevistado por Ma. Alejandra Silva el día 3 de junio de 2005. Nari, Patricia, Silva, María Alejandra et. Al y otros. Caracterización del Eje Socio-político, En: FAO/FODEPAL (2005), Relevamiento de la Situación Actual de la Región para el Desarrollo rural Sustentable, documento de Trabajo- Proyecto 1, Septiembre: pp. 51-63.

[4] Se hizo un relevamiento de los parámetros físicos, químicos y bacteriológicos del agua durante los años 1986, 1987 y 1988. Se comprobó la presencia de valores de nitrato, sulfatos y arsénico que superan el límite admitido.

[5] Con motivo de profundizar sobre el tema se aconseja leer los documentos que se encuentran produciendo académicos de la Fac. de Ciencias Médicas de Rosario junto a profesores-investigadores de Veterinarias, Agrarias, Cs. Económicas y Cs. Políticas. El mismo se refiere a en las características del modelo sojero y su impacto ambiental, social y sanitario y se encuentra en el sitio web

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