Occupational Health and Safety in Brazil
Howard Frummn, MD, MPH, and Volney de M. Camara, MD
Background History Brazil is the world's fifth largest nation, with an area of 8.5 million km2, and the sixth most populous, with approximately 150 million inhabitants.' It is a physically diverse nation, rich in natural resources. Until the 20th century, the economy depended principally on sugarcane, coffee, hardwood, and rubber production, and on gold and diamond mining. Because of fluctuating world markets for these products and dependence on a small number of export products at any time, Brazil's economy oscillated throughout the 19th century. During the 20th century, however, successive national governments have encouraged diversification. Industrialization has proceeded rapidly, and manufacturing now constitutes the largest portion of the gross domestic product. Tremendous economic growth has continued during most of the 20th century, especially during the 1960s and 1970s. However, serious economic and political problems persist, including marked income maldistribution, uncontrolled inflation, and one of the world's largest foreign debts.
particular interest is the gold found in the Amazonas region, which is mined by approximately 600 000 ganimpeiros (goldseekers) working outside the formal sector.2 Mining employs about 4 million people nationally.3 Agricultural production has increased over recent decades as a result of increases in areas under cultivation, but the relative importance of agriculture in the nation's economy has declined with the growth of industry. Major crops include coffee (Brazil is the world's largest producer), soybeans, oranges, and sugarcane; the latter has increased in importance in recent years with use as a source of ethanol for fuel. Other crops include cassava, rice, cacao, and bananas. Brazil also has a sizable forestry industry, producing eucalyptus, pine, and a variety of hardwoods, and a significant fishery. Between 13 and 16 million people, slightly less than one third of the work force, work in the combined agriculture/forestry/ fishing sector, representing a significant decline over recent decades.2,4 Brazil's manufacturing sector is a rapidly growing, vibrant part of the economy. Major products include steel, chemicals, petrochemicals, textiles, automobiles, pulp and paper, aircraft, electronics,
Industry and Agnculture The Brazilian economy includes well-developed mining, agriculture, manufacturing, and service sectors. Rich mineral deposits support an extensive mining industry. There are major deposits of iron ore, bauxite, hematite, oil, and gas in many areas. Aluminum and manganese are mined in the Amazon region, chrome, magnesium, and quartz in Bahia, copper and lead in Bahia and Rio Grande do Sul; asbestos in Goias; and nickel in Goias and Minas Gerais. Brazil is self-sufficient in tin, zinc, and tungsten. Of
At the time of this study, Howard Frumkin was with the University of Pennsylvania School of Medicine. Volney de M. Camara is with the Faculty of Medicine, Universidade Federal do Rio de Janeiro, Brazil. Both are affiliated with (INCLEN) the International Clinical Epidemiology Network. Requests for reprints should be sent to Howard Frumkin, MD, MPH, Division of Environmental and Occupational Health, Emory University School of Public Health, 1599 Clifton Road, NE, Atlanta, GA 30329. This paper was submitted to the journal August 10, 1990, and accepted with revisions May 6, 1991.
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Regulation of Worlqace Conditions
and footwear. The petrochemical industry is Latin America's largest. The manufacturing sector now employs about 25% of the work force, and continues to expand.3.4 Civil construction employs large numbers of workers. The service sector is the fastest growing part of Brazil's economy, and now employs more than one third of the work force. The greatest concentration of industry in Brazil is in the Southeast, centered around the cities of Sao Paulo, Rio de Janeiro, and Belo Horizonte. About one fifth of the nation's industry is in the South, and a very small portion is in the North.
The Brazian Work Force About 45% of Brazil's population, nearly 70 million people, are considered economically active, of whom about 60 million are employed. This includes about 20% of children aged 10 to 14, representing a significant pool of child labor.5 Most Brazilian workers are employed in small workplaces.6,7 However, since no official data are gathered on employment by enterprise size, this trend is difficult to quantify. Women constitute about 35% of Brazil's work force. Female workers tend to have completed more schooling than male workers. Overall, however, women are 1620 American Journal of Public Health
relatively more concentrated than men in the service sector and less concentrated in manufacturing, mining, agriculture, and construction, and they earn lower wages than men.8
Occpautionl Safel and Helh Paice History Awareness of workplace accidents grew in the early years of the 20th century, alongwith larger concerns about the wages and living conditions of workers. Several state-level initiatives during the first two decades of the century addressed the problem of workplace accidents. A national law that regulated workplace safety conditions (Law No. 3724) was promulgated in 1919 and altered in 1934. During the decades of rapid industrialization that followed World War II, the number of reported accidents and their economic burden increased dramatically. The national government took action in 1968 by issuing Ordinance 32, which defined requirements for safety and health initiatives at the workplace level. Since then, further regulations have been promulgated on the federal level and in some states.
The legal framework for occupational health regulation is complex, ranging from the federal constitution (newly issued in 1988) to long-standing Ministry of Labor ordinances. Most occupational health functions have been housed in the Ministry of Labor, but with the reorganization of the health sector in 1988 into the Unified Health System (Sistema Unico de Sauide, or SUS), some responsibility was shifted from the Ministry of Labor to SUS. The new constitution empowers SUS to act in protecting worker health (Article 205, Sections II, VII) but generally does not define how this is to be done. No specific piece of legislation defines a standard-setting process. The constitution does empower the Federal government to conduct workplace inspections (Article 21, Section XXIV). It remains to be seen how regulation and workplace inspection will be conducted by SUS under the new arrangement. For the present, occupational health regulation continues to be an activity of the Ministry of Labor, pursuant to the Consolidated Labor Law of 1943 (Decreto-Lei 5452). In addition to federal activity, state and municipal governments issue some laws and regulations of their own. The Ministry of Labor has generally based its regulations on threshold limit values (TLVs) issued by the American Conference of Governmental Industrial Hygienists (ACGIH).9l10 Of interest, the exposure limits are based on a 48-hour workweek, rather than the 40-hour workweek assumed in US limits. (The longer workweek remains common in Brazil, although the new constitution limited the workweek to 44 hours.) A list of regulated substances appears in Table 1. Several observations maybe made. First, despite the equivalence of many standards (adjusted for differing workweeks), Brazil permits far higher exposure to certain substances, either through more permissive standards or through the complete absence of standards. Second, Brazilian standards based on older ACGIH TLVs have not been updated apacewithACGIH updates. For example, Brazil's methylene chloride standard is based on an older ACGIH TLV that, in the United States, was lowered in 1988. Third, there is far more attention to long-term outcomes, especially cancer, in ACGIH recommendations than in Brazilian regulations. Several carcinogens, such as chromium compounds, are not regulated in Brazil, and others are regulated less stringently. December 1991, Vol. 81, No. 12
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Although some stringent regulations are in place, the Ministry of Labor has maintained virtually no workplace inspection capacity, and little enforcement has occurred. If a violation is discovered, a labor justice may impose a fine, but the maximum fine prescnbed by law is only 10 times the minimum wage for a month (Chapter 5 of Law 5242 of 1943).
Occupational Safety and Health Service Delivery Ordinance 32 of 1968, which was updated in 1983, requires companies to establish an Internal Committee for the Prevention of Accidents (CIPA). Specific requirements for this committee are based on the risk level and on the number of employees.11 The main objectives are the prevention of accidents and the monitoring of safety and health conditions in the plant. Although the committees must contain an equal number of labor and management representatives, the chairman is a management representative. Moreover, although Ordinance 32 protects CIPA labor representatives from discharge because of their committee activity, anecdotal evidence suggests that this protection is sometimes violated. These factors compromise the independence and effectiveness of the workplace committees. In addition to workplace safety and health administration, professional staff requirements are defined by law. A 1972 ordinance (No. 3237) mandated specialized hygiene and occupational medicine services for enterprises according to the number of employees and risk level. For example, a high-risk firm with 1500 employees is required to maintain one occupational physician, one aide, one safety inspector, and one occupational engineer. The ordinance defines the occupational medical role broadly as including preemployment and periodic medical examinations, worker education, surveillance activity, etiologic study, and committee work at the plant level.
Workers' Compensation The workers' compensation function was fully integrated into the nation's larger social welfare system in 1967 by Law 5316, which required all employers to insure their employees through what was then the National Institute for Social Welfare (Instituto Nacional do Previdencia Social, or INPS). Under the restructuring introduced by President Collor de Mello in 1990, the INPS was dissolved. All its social welfare functions, including workers'
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compensation, were transferred to the Ministry of Labor in the newly formed Instituto Nacional de Seguridade Social (INSS). Although some changes may occur, it is likely that the INSS compensation scheme will preserve many of the features it developed under INPS between 1967 and 1990.5 The workers' compensation scheme is called Seguro de Acidentes de Trabalho (SAT). In case of an occupational injury or disease, this scheme offers substantial benefits above ordinary medical coverage. These include medical costs, full wage replacement, compensatory payments for loss of function, rehabilitation costs, and death benefits. The INSS is funded by equal contributions from employees and employers, each composing 10% of the payroll. Because INSS also acts as Brazil's workers' compensation insurance carrier, it collects extra funds to support this function. Payments are collected from employers according to each industry's risk profile. Premiums range from 2.5% ofthe employees' salaries in high-risk enterprises to 0.4% in low-risk enterprises. Risk in this context is evaluated on the basis of lost time accidents (of more than 15 days), a point to which we return below. When an occupational injury or illness occurs, the employer is required to report it to the INSS within 24 hours. The report automatically triggers SAT coverage, which pays for medical care. The employer continues to pay full wages for the first 15 days oflost time, atwhich point the SAT takes over with continued full wage replacement. If a company fails to report an injury or illness, claiming that it is not occupational, then a worker may take the case to labor court. There are many failures of this system.12 First, the SAT scheme includes only about 25% ofthe working population, since only about half of workers are covered by the INSS, and only half of those work for companies required to pay into SAT. Civil servants, physicians, and selfemployed people, for example, would typically be covered by INSS but not by SAT. Rural workers, who constitute close to 30% of Brazil's work force, are also not covered by SAT. Moreover, companies have an incentive not to report injuries and illnesses, mostly a matter of public image rather than finances. This is especially true of injuries that result in less than 15 lost workdays, since the SAT offers wage replacement only after that interval. In addition, physicians often fail to diagnose occupational illnesses correctly, and
workers often are unaware of procedures for submitting injury reports and gaining compensation. For all these reasons, the SAT fails to provide compensation to many workers who become injured or ill at work. The extent of this problem is unknown. Of additional importance, SAT reports are the sole source of occupational injury and illness data in most of Brazil. Some states, such as Rio de Janeiro, require reporting of certain occupational conditions, but this is a variable and incomplete resource. Therefore, the failures of the workers' compensation system translate into failures of occupational health and safety data as well.
Labor Union Activity Approximately 22% of Brazilian workers belong to labor unions.13 The unions have been relatively inactive in occupational health and safety because of restrictions imposed by the military government until 1985 and because of more pressing economic concems. However, some labor unions have recently increased their activity in the field, perhaps supported by growing awareness of environmental devastation in some parts ofthe country with consequent health costs. In 1979 the two labor union confederations, Central Unica de Trabalhadores (CUT) and Confederac,ao Geral de Trabalhadores (CGT), formed the Interunion Department for the Study of Health and Work Environment (Departamento Intersindical de Estudos de Saude e dos Ambientes do Trabalho, or DIESAT). DIESAT advises local unions on safety and health problems, publishes a monthly newsletter, offers seminars, and participates in investigations. The increasing union activity has been evident at the state and national level. In 1980, for example, the "Sindicatos dos Trabalhadores Rurais de Campos-Rio de Janeiro" won a national prohibition of the use of organomercurial fungicides. In 1988, pressure by the keypunchers union, Associacao dos Profissionais de Processamento de Dados (APPD), resulted in recognition by the state government of Rio de Janeiro of tenosynovitis ofthe fingers as a reportable occupational disease among keypunch operators.
Injury and Disease Reporning In Brazil, workplace injuries are defined as "all events that happen during the practice of work directly or indirectly causing physical lesion, functional disturbance or illness, and resulting in death or
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loss of the capacity to work, whether total or partial, temporary or permanent."14 These include injuries at work or while commuting, officially designated occupational diseases, and other diseases found to be work-related. The list of designated causes of occupational diseases (see Table 2) was set forth in December 1976 by Decreto 79.037. For some diseases, Decreto 79.037 specifies particular operations and techniques that are considered pathogenic. This may result in underrecognition of occupational disease; if an operation that causes disease was omitted by the ordinance or was introduced after the ordinance was written, it is not acknowledged as a cause of occupational disease. The report of an injury is the responsibility of the employer. After the employer has been informed ofthe injury, the Ministry of Labor must be notified within 24 hours and given a description of the injury.11 These data are tabulated, but very little further analysis is performed. There is no systematic effort to identify hazardous enterprises or to apply these data to enforcement or policy decisions. One source of error in injury statistics derives from the fact that commuting injuries are notifiable. When a worker is injured over the weekend, he or she might report that injury as a commuting injury upon arriving at work Monday morning. This phenomenon is apparently common in some companies, although difficult to quantify. It may partially explain the peak in injuries seen on Mondays (data not
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Medical and nursing curricula in Brazil vary in their occupational safety and health content. In major universities in Rio de Janeiro, Sao Paulo, and Minas Gerais, considerable time is devoted to occupational safety and health. For example, the medical curriculum at the Federal University of Rio de Janeiro includes 126 contact hours in occupational medicine during the third year. Other universities have considerably less instruction in occupational safety and health. Specialty training in occupational safety and health was greatly promoted by the 1972 ordinance that requires occupational physicians, industrial hygienists, and occupational health nurses at plants. These functions were initially well salaried in a nation that suffers from professional unemployment, so large numbers of physicians and nurses sought certification. Within several years, universities responded to the increased demand by offering large numbers of training programs. The result was a large complement of occupational safety and health professionals by the late 1970s; over 20 000 occupational physicians were trained during that decade.15 Presently, about 10 universities throughout the nation offer specialty training in occupational medicine, occupational nursing, and industrial hygiene. Certification in occupational medicine or nursing requires 360 hours of instruction over 1 year, usually taken as an evening course. Upon completion of the course, the Ministry of Labor certifies graduates, which qualifies them to fill the role defined by law. This function may be taken over by the Ministry of Education in coming
Avaible Data on Occupational Injuries and Diseases The data in this report are derived from the population covered by the SAT scheme. Although the Ministry of Labor must be notified of all workplace injuries, only those injuries resulting in at least one lost workday are reported. In contrast, most other countries' data are based on 3-day lost work time injuries. The numerator data reported here were obtained from the INPS, and the denominator data were obtained from the Brazilian Institute for Geography and Statistics, or IBGE.8A foundation based in the Ministry of Labor, FUNDACENTRO, also publishes workplace injury reports in its bulletins, again based on INPS data.
Figure 1 shows the occupational injury incidence rate (including both occupational diseases and transit injuries) per 100 employees. Despite the deficiencies in reporting, the data indicate that Brazil has a high incidence of occupational injuries. This rate increased until 1972 and decreased thereafter. At least two explanations may be offered for the change: improving working conditions or less complete reporting of injuries. In support of the first explanation, at least two developments may be cited. One is the legislation that mandated plant-level occupational health services. Second, increased training in occupational safety and health at the university level might have contnbuted to a decrease in workplace injuries. In support of the second explanation, several observations are relevant. First, as noted above, most of the Brazilian working population is employed in small enterprises that were not required to establish Internal Committees and Occupational Health Services. Second, a major change in Brazil's insurance legislation occurred in 1975. Until then, the employer was required to pay a worker's salary on the day of a workplace injury, while the INPS assumed this role on the second day. After 1975, employers were required to pay the injured worker's salary until the 15th day after the injury. This change was a powerful incentive for companies not to report injuries. Unfortunately, the Ministry of Labor has not monitored companies' compliance in recording and notifying injuries, so the extent of underreporting is unknown. Several other observations suggest that the reported data are underestimates. First, the SAT data cover only about 25% of the work force, excluding especially hazardous sectors such as agriculture. Second, the number of reported occupational diseases (which are included in injury data) is very low. Physicians in Brazil are still not familiar with the relationship between work and health,12 and specialized diagnostic services such as toxicological laboratories are rare. Finally, the apparent decrease in occupational injury incidence did not correspond to a similar decrease in the occupational fatality rate. In Brazil, as in other developing countries, mortality records are usually more reliable than morbidity and other data. Figure 1 shows that the case fatality rate increased from 1970 through 1987. The likely explanation is that fatal injuries continued to be notified, while nonfatal injuries did not. Although international comparisons are December 1991, Vol. 81, No. 12
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difficult, it appears from available data that Brazil's workplace fatality rate is significantly above that of other countries, as shown in Table 3. Figure 2 shows the proportion of occupational diseases and transit injuries included in the total number of injuries. Reported cases of occupational disease have never exceeded 1% of the total, probably reflecting significant underreporting of disease. On the other hand, there has been an increasing trend in transit injuries, reflecting better reporting and/or increasing risk in a nation with increasingly congested and dangerous roads. The rate of occupational disease notification in Brazil was estimated during a study of organomercury fungicide use by sugarcane workers in the district of Campos, State ofRio de Janeiro.16 For the year 1980, 1456 occupational injuries were registered, including one occupational disease. In this same year, 30 sugarcane workers were submitted to a clinical and laboratory examination, which revealed 21 cases of mercury poisoning with blood levels of mercury as high as 0.25 ppm. None of the 21 affected workers was among the 1456 reported cases, suggesting widespread underreporting.
Conclusions Several conclusions emerge from this review of occupational health and safety in Brazil. First, there is a high incidence of occupational injuries and diseases. This is common among developing countries, often to a worse degree than in developed nations. Brazil illustrates the tension that may exist between economic development and attention to health concerns. In nations with crushing foreign debts, like Brazil, the economic crisis may eclipse less immediate and pressing concerns such as occupational safety and health. Constituencies that might promote safety and health measures, such as labor unions and the health sector, are forced in this situation to direct their efforts to other issues. This tension exists in all developing nations, and may be expected to continue in the foreseeable future. It highlights the importance of greater attention to occupational health in Brazil, and of vigorous attempts to prevent injuries and illnesses. Second, there is evidence of serious underreporting of occupational injuries and illnesses, worse with illnesses than with injuries. Among the most important reasons are the exclusion of a majority of the work force from the only systematic
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Incidence and Fatality Rates
Workers under SAT (millions)
Number of workers
+ Incidence rate
Case fatality rate
Sources: INPS, IBGE
FIGURE 1 Occupaffonal injury incidence (per 100 workers) and case fatality (per 1000 Injuries) rates, Brail, 1970-1987.
data collection system, reliance on employers for notification despite incentives against notifying, and underdiagnosis of occupational diseases by physicians. On the other hand, two factors may increase reporting relative to other nations: the inclusion of injuries that occur while commuting and the reporting of injuries that result in as little as one lost workday. In any case, more consistent, standardized injury and disease surveillance is clearly required. A third conclusion relates to the informal sector of Brazil's economy. As is the case in many developing nations, a large portion ofBrazil's work force is marginalized and excluded from services. Examples include the street vendors who are ubiquitous on the streets of major cities, agricultural workers, and the gold-seekers in the Amazon basin. These groups may be at special risk of occupational injury and disease, and special efforts must be made to extend surveillance and prevention programs to them. Brazil also illustrates the disparity that may exist between legislation "on the books" and reality. It has a relatively complete set of laws that relate to occupational safety and health, but enforcement is erratic and generally absent. As a result, hazardous conditions persist in many workplaces. Similarly, although national legislation triggered training of a large number of occupational health professionals, especially physicians, this group has not had the impact on workplace conditions that might have been
hoped. These observations suggest that vigorous action by regulators, labor unions, and professionals may be necessary to achieve real change. An interesting and unusual feature of Brazil's occupational health landscape is the integration of almost all occupational health services into the health sector. Historically, the provision of social services has been tied to work. Almost 25 years ago, the workers' compensation function was integrated into the INPS, although American Joumal of Public Health 1623
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= Transit Injuries
FIGURE 2-OccupatIonal diseases and ansit Injuries as a proportion of all occupational Injuries, Brazil, 1970-1987.
separate sites for delivering occupational medical services were maintained. In recent years, especially with the new constitution, other functions such as workplace inspection seem to be moving from the Ministry of Labor to the Ministry of Health, although some reversal of this trend occurred in 1990 under the new govermient. The effects of this change remain to be seen, but if successful, it offers some promise of decreased intersectoral disputes and a more efficient government role in occupational safety and health. El
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References 1. US Department of State. Brazil: Background Notes. Washington DC: Department of State; 1990. 2. Couto RC, Camara VM, Sabrosa P. Intoxicaqao mercurial: resultados preliminares em duas areas garimpeiras. Cademos de
Saiude Coletiva. 1988;4:301-315. 3. Brazil. In: Encyclopaedia Bnitannica. 15th ed. Chicago, Ill: Encyclopaedia Britannica Inc; 1987:15:188-212. 4. International Labour Office. Year Book of Labour Statistics, 1989-90. Geneva: ILO; 1990.
5. Tambellini AT. Politica nacional de saude do trabaihador: aldnises e perspectivas. Rio de Janeiro: FIOCRUZ; 1986. Mimeo. 6. Possas C. Saude e Trabaiho: A Cise da Previdencia Social. 2nd ed. Sfio Paulo, Brazil: Ed. Hucitec; 1983. 7. Mendes R. Importancia dasPequenas Empresas Industniais no Problema Dos Acidentes de Trabalho. Sao Paulo, Brazil: Tese de Mestrado, Universidade do Sao Paulo; 1975. 8. Instituto Brasileiro de Geografia e Estatistica. Pesquisa Nacional por Amostra de Domicilios-1987. Rio de Janeiro, Brazil: Instituto Brasileiro de Geografia e Estatistica; 1988. 9. Ministerio do Trabalho. Curso de Medicina do Trabalho. SaoPaulo: Fundacentro; 1979. 10. Ribeiro HP, Lacaz FA de C. De QueAdoecem e Morrem os Trabalhadores. Sao Paulo: Ed. Diesat; 1984. 11. Manual de Legislacao Atlas. Seguran,a e medicina do Trabalho, 9' Edicao. Rio de Janeiro, Brazil: Ed. Atlas; 1984. 12. Mendes R. Perfil de morbi-mortalidade dos trabalhadores no Brasil. Presented to SBPC, Porto Alegre; 1990. Mimeo. 13. US Department of Labor, Bureau of International Labor Affairs. Foreign Labor Trends: BraziL Washington, DC: US Department of Labor. FLT 90-31. 14. Diario Oficial do Brasil, May 3 1944. 15. Relat6rio da I Reuniao Nacional sobre Ensino e Pesquisa em Saude Puiblica, Relat&rio Final. In: Ensinoda SauidePgiblica, MedicinaPreventiva e Social doBrasiL Rio de Janeiro, Brazil: ABRASCO; 1984. 16. Silva MRC, Camara VM, Senone M. Oticzawo eigon6mica dos tratos cukurais da lavoura de cana-de-a,ucar. 40 Relat6rio Tecnico, Fundacao Getulio Vargas, UFRJ, Rio de Janeiro; 1980. Mimeo. 17. Norma Regulamentadoras Portaria 3214 de 8 de Junho de 1978. 18. American Conference of Governmental Industrial Hygienists. Threshold limit values and biological exposure indices for 198990, Cincinnati, 1989.
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