21/42 Report of the Special Rapporteur on the human right to safe drinking water and sanitation, Catarina de Albuquerque Stigma and the realization of the human rights to water and sanitation

GE.12-14898

Human Rights Council Twenty-first session Agenda item 3 Promotion and protection of all human rights, civil,

political, economic, social and cultural rights,

including the right to development

Report of the Special Rapporteur on the human right to safe drinking water and sanitation, Catarina de Albuquerque

Stigma and the realization of the human rights to water and sanitation

Summary

The Special Rapporteur on the human right to safe drinking water and sanitation submits the present report in accordance with Human Rights Council resolution 16/2. She focuses on the links between stigma and the human rights framework as it relates to water and sanitation. She has found that stigma, as a deeply entrenched social and cultural phenomenon, lies at the root of many human rights violations and results in entire population groups being disadvantaged and excluded.

The Special Rapporteur seeks to convey an understanding of stigma and to elucidate its drivers. She links stigma explicitly to water, sanitation and hygiene before examining different manifestations of stigma. She situates stigma in the human rights framework considering, in particular, human dignity, the human rights to water, sanitation, non-discrimination and equality, the prohibition of degrading treatment, and the right to privacy. Based on this analysis, the Special Rapporteur seeks to identify appropriate strategies for preventing and responding to stigma from a human rights perspective, before concluding with a set of recommendations. She emphasizes that States cannot fully realize the human rights to water and sanitation without addressing stigma as a root cause of discrimination and other human rights violations.

Contents

Paragraphs Page

I. Introduction ............................................................................................................. 1–11 3

II. Understanding stigma and its drivers ...................................................................... 12–21 4

III. Stigma and its links to water, sanitation and hygiene .............................................. 22 6

IV. Manifestations of stigma ......................................................................................... 23–42 6

A. Rendering people and their needs invisible .................................................... 24–28 7

B. Pushing people to the margins of society........................................................ 29–35 8

C. Excluding people from facilities ..................................................................... 36–37 10

D. Ostracism within one‘s own family ................................................................ 38 10

E. Threats to privacy and security ....................................................................... 39–40 11

F. Criminalization ............................................................................................... 41–42 11

V. Situating stigma in the human rights framework..................................................... 43–57 11

A. Human dignity ................................................................................................ 44 12

B. Human rights to water and sanitation ............................................................. 45–47 12

C. Non-discrimination and equality..................................................................... 48–51 13

D. Prohibition of inhuman or degrading treatment .............................................. 52–54 14

E. Right to privacy .............................................................................................. 55–57 14

VI. Identifying appropriate strategies for prevention and response ............................... 58–77 15

A. Participation and empowerment ..................................................................... 60–63 16

B. Awareness-raising to break taboos and challenge stereotypes ........................ 64–69 17

C. Legislative, policy and institutional measures ................................................ 70–71 18

D. Adopting targeted interventions ...................................................................... 72–73 19

E. Adopting technical measures .......................................................................... 74–75 19

F. Ensuring access to justice ............................................................................... 76–77 19

VII. Conclusions and recommendations ......................................................................... 78–82 20

I. Introduction

1. The present report is submitted by the Special Rapporteur on the human right to safe drinking water and sanitation in accordance with Human Rights Council resolution 16/2. It is focused on the links between stigma and the human rights framework as it relates to water and sanitation.

2. The Special Rapporteur has repeatedly encountered incidences of lack of access to water and sanitation, where people in particular groups are systematically neglected compared to the rest of society. Those in power appear to be indifferent to their problems, or in the worst case, to be under pressure from society as a whole not to take any measures to improve service provision. Decision makers at times deploy stigma to ―justify‖ their lack of political will to provide access to services for the marginalized, favouring policies that are popular in the broader society. The Special Rapporteur has been confronted with reluctance by decision makers to take action to overcome such neglect or exclusion, prompting her to examine these situations systematically.

3. The Special Rapporteur has found that stigma, as a deeply entrenched sociocultural phenomenon, lies at the root of many human rights violations, resulting in entire population groups being disadvantaged. It is so engrained that marked cases of human rights violations are perceived as ―acceptable‖. The Special Rapporteur seeks to shed light on the impact of stigma as the cause of neglect and exclusion in the enjoyment of the rights to water and sanitation and to explore recommendations for policymaking and appropriate solutions to address, prevent and respond to such human rights violations.

4. Stigma and discrimination are closely interrelated; they reinforce and legitimize each other. Stigma often lies at the root of discrimination; it is an antecedent to and a rationale for discrimination. It provides a ―justification‖, so that discrimination is seen as natural, necessary and desirable. Stigma plays an insidious role in making systemic discrimination possible. The Committee on Economic, Social and Cultural Rights has found that ―discrimination against some groups is pervasive and persistent and deeply

entrenched in social behaviour and organization‖.1

5. Stigma gives rise not only to discrimination, but also to a range of other human rights violations, both of economic, social and cultural rights as well as civil and political rights, underscoring the indivisibility of all human rights. Where people are excluded from the use of facilities, where they find themselves unable to access public toilets and have no alternatives, or where people are threatened with violence and fear for their physical and mental integrity, this may result in violations of the human rights to water and sanitation and other related rights, inter alia, the prohibition of inhuman and degrading treatment or the right to privacy.

6. Identifying human rights violations as rooted in stigma demands an exploration of the origins of discrimination and other human rights violations. To start, speaking openly about what seems ―unmentionable‖ can act as an eye-opener, precisely because stigma is instrumental in propagating silence and imposing a culture of invisibility and shame, allowing human rights violations to continue unabated and with impunity.

7. The Special Rapporteur is aware that carelessly reporting attributes assigned to individuals and groups may, in fact, unintentionally further entrench the stigma wielded against them. To mitigate this risk, she uses quotation marks whenever she refers to such

1 General comment No. 20 (2009) on non-discrimination in economic, social and cultural rights,

para. 12.

ascribed characteristics. Moreover, she believes that the benefits of speaking openly about the experience of stigma far outweigh these concerns. She considers it necessary to tackle the very topics masked by stigma, which are seen as uncomfortable or taboo.

8. At the same time, the focus on stigma limits the scope of the report. The report does not cover all groups that are disadvantaged in terms of access to water and sanitation. There are other, often heinous, forms of discrimination and other human rights violations that disadvantage certain individuals and groups. Indirect discrimination is also prohibited, that is, discriminatory actions that are not based on stigma, prejudices or stereotypes, but simply have an unintended discriminatory effect. Other forms of discrimination may be direct and deliberate, while not being based on stigma. The Special Rapporteur addresses many such situations in other areas of her work, but in the present report she focuses on violations of the human rights to water and sanitation emanating from stigmatization, enabling her to conduct a detailed analysis and identify appropriate response measures.

9. The scope of the report is guided by the Special Rapporteur‘s mandate: the human right to water and sanitation. Hence, it covers some experiences and manifestations of stigma rather than all dimensions of people‘s lives. The issues highlighted are only a few along a continuum of human rights concerns that stigmatized people face. Still, the Special Rapporteur believes that exploring the impacts of stigma through the lens of water, sanitation and hygiene highlights its pervasive nature in preventing people from leading a life in dignity.

10. To approach this work, the Special Rapporteur engaged in a wide consultative process, including an expert consultation held in Geneva in January 2012 with key individuals speaking on their own experience of stigma, civil society organizations, academia, international organizations and independent consultants. She also held a public consultation attended by over 80 participants, including more than 50 State delegations, and received about 50 written contributions. 2 These discussions have provided her with valuable guidance in preparing the present report, and she is grateful to all those who contributed. She also expresses her gratitude to the numerous people she has met over the past four years who have enabled her to understand the amplitude and dimensions of stigma.

11. In the report, the Special Rapporteur first seeks to convey an understanding of stigma and to elucidate its drivers. She links stigma explicitly to water, sanitation and hygiene before examining different manifestations of stigma. She situates stigma in the human rights framework considering, in particular, human dignity, the human rights to water and sanitation and other related rights, such as non-discrimination and equality, the prohibition of degrading treatment and the right to privacy. Based on this analysis, the Special Rapporteur seeks to identify appropriate strategies for preventing and responding to stigma, and concludes with a set of recommendations.

II. Understanding stigma and its drivers

12. Stigma relates closely to power and inequality, and those with power can deploy it at will. Stigma can broadly be understood as a process of dehumanizing, degrading, discrediting and devaluing people in certain population groups, often based on a feeling of disgust. Put differently, there is a perception that ―the person with the stigma is not quite

2 Available from the website of the Special Rapporteur:

www.ohchr.org/EN/Issues/WaterAndSanitation/SRWater/Pages/Contributionsstigmatization.aspx.

human‖. 3 Stigma attaches itself to an attribute, quality or identity that is regarded as ―inferior‖ or ―abnormal‖. Stigma is based on a socially constructed ―us‖ and ―them‖ serving to confirm the ―normalcy‖ of the majority through the devaluation of the ―other‖.4

13. What is considered ―abnormal‖ changes over time and place, while the targets of stigma are always those who do not fit the ―social norm‖. In some instances, stigma is attached to a person‘s social identity, especially in relation to one‘s gender or gender

identity, sexual orientation, caste or race. Many ethnic groups experience very pronounced stigma. Stigma is also a common reaction to health conditions such as HIV/AIDS and some forms of disabilities. The Committee on Economic, Social and Cultural Rights explicitly calls on States to ―adopt measures to address widespread stigmatization of persons on the basis of their health status, such as mental illness, diseases such as leprosy and women who have suffered obstetric fistula‖.5 Indeed, stigma is often closely linked to the body as a site of the ―normal‖ and the ―different‖ and as a vehicle of contagion, especially in terms of sexuality and disease. Furthermore, stigma is frequently attached to activities that are considered ―immoral‖, ―detrimental to society‖ or ―dirty‖, affecting, for instance, sex workers, sanitation workers, prisoners and homeless people.

14. In many instances, stigma is compound, multiple or intersectional, meaning that a single person can possess different attributes to which stigma are attached, such as in the case of an ex-prisoner who is homeless. Individuals experiencing compound stigma are often the ones who are most marginalized and discriminated against. The concept of intersectionality recognizes that individuals have multiple identities, attributes and behaviours, and that the intersections of these multiple aspects give shape to experiences of stigmatization and discrimination. Individuals falling into a particular category do not all inhabit the same social positions.

15. People who are stigmatized can find it is almost impossible to escape the stigma. Similarly, some may experience stigma by association, that is, extending beyond a person with a particular attribute. The Committee on Economic, Social and Cultural Rights has found that people may be discriminated against by being associated with or by being perceived as part of a particular group.6 For example, during her mission to Bangladesh, the Special Rapporteur found that the occupation as ―sweeper‖ is passed down through generations and that people in that occupation feel ―trapped‖ (A/HRC/15/55 and Corr.1, paras. 26, 75 and 76).

16. At a fundamental level, stigma reflects unequal power. Power can be about the ability to define standards of what is ―normal‖ and ―acceptable‖. Stigma can be created to the detriment of some, while being to the ―benefit‖ of others. It is not only those at the top of any societal hierarchy who stigmatize. Stigma is deeply entrenched in any society and plays out within particular groups, as no group has a monolithic identity. Stigma can be deployed wilfully and strategically, and perpetuates patterns of inequality. It is an element of the structural and social dynamics which (re)produce unequal power relations.

17. Power relationships result in the marginalization and exclusion of certain groups and individuals from decision-making processes, access to resources and services, and the ability to shape social life. Stigma supplies the world view for marginalization by ―legitimizing‖ the process of setting up and perpetuating an ―us and them‖ divide, and through the devaluation and dehumanization of those seen as being outside the ―us‖.

3 Erving Goffman, Stigma: Notes on the Management of Spoiled Identity (New York, Simon &

Schuster, 1963), p. 5. 4 Ibid., p. 138. 5 General comment No. 20, para. 33. 6 Ibid., para. 16.

18. Understanding how stigma relates to social power, marginalization and exclusion also reveals the drivers of stigma, which lie in the individual, social, cultural and institutional spheres. Individuals across society contribute to the creation and continuation of stigma. Often, prejudices and stereotypes persist across generations, and are combined with irrational fears—of contagion, ―impurity‖ or ―otherness‖. This is frequently exacerbated by a lack of access to accurate information, for example on the transmission of diseases. In many instances, people are not aware that they are stigmatizing certain groups, since their stereotypes are widely prevalent in society, considered ―normal‖ and ―acceptable‖.

19. Stigma can also be felt as personal shame, guilt and embarrassment, referred to as internalized stigma. It manifests itself in self-exclusion from services or opportunities, low self-esteem, negative self-perceptions, social withdrawal, and fear of disclosure of one‘s stigmatized status.

20. Stigma also has its drivers at the societal level with, for instance, the media contributing to spreading prejudices and stereotypes. It is also driven by deeply entrenched cultural beliefs relating, for instance, to gender, sexuality, health and descent. Caste systems are striking examples of systems that lead to the stigmatization of large parts of the population, potentially amounting to violations of human rights.

21. These drivers of stigma in the individual, social and cultural spheres find their reflection at the institutional, structural and policy levels. Politicians often win votes by proposing populist policies reflecting public attitudes. Instead of combating stigma, legislative, policy and institutional frameworks may reflect stigmatizing attitudes, further entrenching stigma by institutionalizing, formalizing and legitimizing it.

III. Stigma and its links to water, sanitation and hygiene

22. Stigmatization often results in lack of access to water and sanitation and poor hygiene standards. The lack of access to essential services is a symptom, while the root causes lie in stigmatization. Only through an understanding of these causes will it be possible to implement effective measures to improve access to services. Stigma is often closely linked to perceptions of uncleanliness, untouchability and contagion. In many instances, stigmatized people are perceived as ―dirty‖, ―filthy‖ and ―smelly‖, affecting for instance homeless populations, menstruating women and girls, Roma communities, Dalits or women suffering from obstetric fistula.7 Individuals who find themselves stigmatized because of the perception that they are ―dirty‖ or ―contagious‖ may be socially ostracized and be denied access to water, sanitation and hygiene services, hence reinforcing the stereotype of uncleanliness and prolonging a vicious circle. It is not their inherent condition to live in filthy and poor conditions; it is a position imposed by society that uses stigma as a tool to create, perpetuate and justify marginalization and inequality.

IV. Manifestations of stigma

23. Stigma manifests itself in different ways, combining ostracism, abandonment, shunning, rejection, isolation, exclusion, bullying, discrediting, blaming, harassment,

7 Obstetric fistula is a medical term which refers to a hole which develops either between a woman‘s

rectum and vagina, or between a woman‘s vagina and bladder (or both), as a result of obstructed

labour, resulting in constant urinary and/or faecal incontinence. See World Health Organization (WHO), ―10 facts on obstetric fistula‖ (2010).

physical violence, among many others, but fundamentally all these manifestations relate back to the process of devaluing and dehumanizing individuals in certain groups and creating an ―us and them‖ divide. Different people experience stigma in different ways, and the extent to which certain manifestations apply differs. The examples mentioned are for illustrative purposes only. They are not meant to imply that particular groups experience stigma exclusively in one way or another, or that other manifestations would relate only to other groups.

A. Rendering people and their needs invisible

24. Stigma has a perverse effect of silencing. It creates taboos and results in issues not being addressed. Stigma renders some people and their needs invisible in society. For instance, denying the practice of ―untouchability‖ and the resulting silence that surrounds it is part of the stigma. Similarly, millions of people suffer from neglected tropical diseases,8 particularly the poorest in isolated rural areas. For the most part they are invisible in public health planning, research and treatment. Several of these diseases are linked to poor water and sanitation conditions, and have traditionally been a source of stigma and isolation. The fact that stigma is often internalized further contributes to the silencing effect by preventing people from bringing up certain issues due to their acceptance of the stigma. This silence results in denial that human rights violations exist—they are not seen, thought about or addressed.

25. The silence and stigma surrounding menstruation makes finding solutions for menstrual hygiene management a low priority. Menstruating women and girls often lack a private place to change or wash the rags used. Menstruation has many negative cultural attitudes associated with it, including the idea that menstruating women and girls are ―contaminated‖, ―dirty‖, ―impure‖ or ―polluted‖. These manifest in practices such as the seclusion of women and girls, reduced mobility, dietary restrictions, and/or women and girls being required to use different water sources or prohibited from preparing food for others during menstruation—practices that are often deeply rooted in sociocultural and patriarchal interpretations of religious prescriptions. Even where such restrictions are not followed, women and girls may continue to harbour internalized stigma and are embarrassed to discuss menstruation. The lack of privacy for cleaning and washing, the fear of staining and smelling, and the lack of hygiene in school toilets are major reasons for being absent from school during menstruation, and have a negative impact on girls‘ right to education.9

26. The invisibility created by stigma also has negative impacts on the situation of some persons with disabilities. The World Health Organization estimates that over 1 billion people worldwide live with some kind of physical, mental, intellectual or sensory impairment.10 However, due to the silence and shame created by stigma, persons with disabilities and their needs are often rendered invisible, making it impossible for them to enjoy a range of human rights, as most practices, services and facilities are biased against them. In some societies, persons with disabilities are perceived as ―problems to be fixed‖ or as a ―burden‖. According to information received by the Special Rapporteur, in extreme cases, children and adults with mental disabilities have literally been tied up inside the home—with no access to sanitation—to hide them from the community.

8 See WHO, Accelerating Work to Overcome the Global Impact of Neglected Tropical Diseases: A

Road Map for Implementation (Geneva, 2012). 9 See United Nations Children‘s Fund (UNICEF), Equity in School Water and Sanitation: Overcoming

Exclusion and Discrimination in South Asia – A Regional Perspective. 10 WHO, World Report on Disability (Geneva, 2011), p. 29.

27. Some older persons might also face stigma, in particular when suffering dementia or other mental illnesses and requiring care, including for their sanitation and hygiene needs. Incontinence is not uncommon, but usually not openly addressed. Again, stigma can contribute to making the particular needs of older persons invisible, preventing the care they require and isolating them.

28. The silencing effect of stigma is pronounced in relation to prisoners, who are often forgotten and neglected. Prison conditions, including concerning water and sanitation, are notoriously substandard in many parts of the world. The Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment has noted that in many countries ―authorities simply do not regard it as their responsibility to provide detainees with the most basic services necessary for survival, let alone for a dignified existence or ... an ‗adequate standard of living‘ ‖ (A/64/215 and Corr.1, para. 43). In one country he found that ―it is the task of [the detainees‘] families to bring them water in plastic bottles and food in plastic bags. Since there are no toilets, they must use the same bottles to urinate and the plastic bags to defecate‖ (ibid.). In another country he was confronted with ―detainees [using] the water in the toilets for drinking‖ (ibid., para. 44). There is often a perception that prisoners ―deserve‖ inadequate services and that scarce resources should not be used to improve prison conditions. The stigmatization of prisoners results in low priority given to their needs and a failure to meet basic human rights standards.

B. Pushing people to the margins of society

29. Stigma is also manifest in the rejection, avoidance and marginalization of certain groups, quite literally pushing people to the margins of society. Racist and similar attitudes demean, degrade and dehumanize groups of people because of their racial, ethnic, religious, linguistic or caste identity. Many racial and ethnic groups or castes experience stigma, including indigenous peoples, pastoralists, (semi-)nomadic tribes such as the Bedouins, persons with albinism, Roma in Europe and Dalits in South Asia. They may suffer from pervasive negative stereotyping, social exclusion and denial of fundamental human rights. In some instances, people are forced to live at the outskirts of cities and villages, sometimes being relocated to more remote areas, subjected to an ―out of sight, out of mind‖ attitude.

30. In some situations, indigenous peoples may be stigmatized as ―primitive‖ and pursuing an ―uncivilized‖ lifestyle. In her missions to Costa Rica and to the United States of America, the Special Rapporteur observed that indigenous communities are disproportionately excluded from access to water and sanitation. 11 Similarly, pastoralist communities and (semi-)nomadic tribes are often neglected in terms of access to services.12 State policies may seek to ―civilize‖ indigenous, pastoralist or nomadic communities, pushing them to live on reserves or in urban slums, with substandard water and sanitation services even in these areas, highlighting how attitudes, stigmatization and public policies mutually reinforce each other to the detriment of these communities.

31. The situation is similar for many ethnic groups across the globe. Access to water and sanitation for Roma is notoriously precarious. It is not uncommon for Roma communities, including those living in countries where non-Roma communities have universal access to water and sanitation, to lack even rudimentary access, as found by the Special Rapporteur

11 Reports of the Special Rapporteur on her missions to Costa Rica (A/HRC/12/24/Add.1 and Corr.1),

para. 48, and to the United States (A/HRC/18/33/Add.4), paras. 61-69. 12 See, for example, Sharmila Murthy and Mark Williams, ―The complicated nature of stigma: realizing

the human rights to water and sanitation for Bedouins in the Negev, Israel‖, submission to the Special Rapporteur.

during her mission to Slovenia (A/HRC/18/33/Add.2, paras. 33-36). This situation highlights one of the insidious qualities of stigma: it has a self-fulfilling and circular nature. Roma are stereotyped as being ―dirty‖, ―smelly‖ and ―unclean‖ while being denied access to water and sanitation. Sometimes, well-meant interventions can reinforce their stigmatization. Reportedly, some municipalities in Eastern Europe have implemented shower programmes in schools, encouraging Roma children to take a shower before entering the classroom—with the unintended effect of identifying them as being too ―dirty‖ to receive education and as such further entrenching their stigmatization.13

32. Similarly, caste systems are closely related to stigma and patterns of human rights violations. Caste systems across the world are deeply rooted in social segregation, based on ideas of purity and pollution and lending traditional ―legitimacy‖ to discrimination. The International Dalit Solidarity Network underlines that Dalits ―are considered ‗lesser human beings‘, ‗impure‘ and ‗polluting‘ to other caste groups. They are known to be ‗untouchable‘

and subjected to so-called ‗untouchability practices‘ in both public and private spheres‖.14

In terms of water and sanitation provision, Dalit habitations are often systematically excluded (A/HRC/15/55 and Corr.1, para. 76).

33. Dalits are regularly forced into the most menial, socially degrading, dirty and hazardous jobs. Some Dalits, in particular women, work as manual scavengers or sweepers; the terminology varies across countries, but generally refers to those who clean faeces from dry toilets.15 As a result of their direct contact with human faeces, manual scavengers suffer from a range of health problems (A/HRC/15/55 and Corr.1, para. 75) that are for the most part left untreated and add further to their stigmatization. Manual scavengers and sweepers suffer extreme forms of social exclusion, even within their own caste. These practices are not only deeply rooted in society, but also institutionalized through State practice, with municipalities themselves employing sweepers (ibid.). Moreover, patterns of stigmatization are perpetuated in schools, being reflected in the nature of cleaning duties, namely, through the assignment of toilet cleaning to the ―lower‖ castes.16 Instead of breaking caste barriers, teachers perpetuate stigmatization, limiting the rights of young people to be free from discrimination and to access education.

34. All over the world, toilets are associated with dirt, disease and disgust, and an occupation in this field correlates with lower social status. Sanitation workers are often insulted and attacked when carrying out their work and in some places are forced to work at night to conceal the nature of their tasks. Although sanitation workers in developed countries do not perform unhygienic work to the same extent, benefiting from protective gear and advanced sanitation systems, they also often face disrespect and rejection. 17 Undocumented migrant workers often carry out jobs that no one else wants to do, such as sanitation work, and may lack the protections that apply to the working conditions of the formal work force.

35. People living in poverty, homeless persons, pavement dwellers, street children and slum dwellers also face stigmatization and are frequently forced to exist at the margins of society. The Committee on Economic, Social and Cultural Rights has found that a person‘s

13 François-Xavier Bagnoud Center for Health and Human Rights, Harvard University, ―Water and

stigma: school shower programs for Roma children in Eastern and Central Europe‖, submission to the Special Rapporteur, first page.

14 International Dalit Solidarity Network, Annual Report 2010, p. 5. 15 See, for example, ―India‘s manual scavengers: clean up‖, The Economist, 10 July 2008. 16 UNICEF, Equity in School Water and Sanitation (note 9 above), pp. 20 ff. 17 See WASH United, ―Stigmatization in the realisation of the right to water and sanitation‖, submission

to the Special Rapporteur.

social and economic situation when living in poverty or being homeless may result in pervasive discrimination, stigmatization and negative stereotyping, which can lead to unequal access to services.18 People living in poverty face a range of barriers in accessing water and sanitation services, including a perception that they are to be blamed for their poverty and do not deserve adequate services. Homeless people and street children are frequently blamed for their homelessness, and labelled as ―mentally deficient‖, ―criminals‖ or ―addicts‖. Children living in dilapidated surroundings—without a social safety net, and without access to safe water and sanitation—may see those surroundings as a reflection of their own self-worth,19 hence growing up with low self-esteem and embarrassment. Slums and informal settlements are often not taken into account in urban planning. People living in slums are often simply absent from official records and urban plans; there is a perception that ―they do not count‖, once again highlighting the dehumanizing nature of stigma.

C. Excluding people from facilities

36. Stigma often manifests itself in exclusion from social gatherings or everyday activities. Many people affected by stigma also experience the impact of stigma in their access to shared or common water and sanitation facilities. Reportedly, Dalits have been unable to collect water from shared wells or have been fined for drinking from a common water tap, and Dalit women have reportedly had to wait in a separate queue until non-Dalits have fetched water. Large-scale violence and physical attacks by members of the dominant caste have been reported where Dalits attempted to access facilities in areas inhabited by the dominant caste.20 Similarly, people living with HIV/AIDS have sometimes been locked out of communal latrines or water taps by their neighbours.21

37. Excluding people from water and sanitation facilities creates a vicious circle of further entrenching stigmatization. For instance, not providing homeless persons with the opportunity to use public facilities forces them to resort to urinating and defecating in public, without being afforded any privacy. In being so exposed, people are stigmatized even further.

D. Ostracism within one’s own family

38. Stigmatization is not limited to the public sphere. For instance, many people living with HIV/AIDS face stigmatization within their families. Similarly, women with obstetric fistula are often stigmatized, due to the leaking of urine and sometimes faeces, resulting in a constant wetness and foul odour. The stigma associated with fistula demonstrates how closely the external and internalized dimensions of stigma are intertwined. Women suffering from fistula are often deserted by their family and friends while also feeling ashamed and disgraced; they often ―eat alone, sleep alone, and pray alone‖.22 Lack of access to water and sanitation worsens the situation and reinforces the stigma against such women, who need to wash and bathe more frequently.

18 General comment No. 20, para. 35. 19 Preliminary study of the Human Rights Council Advisory Committee on the promotion of human

rights of the urban poor: strategies and best practices (A/HRC/AC/8/5), para. 9. 20 See National Campaign on Dalit Human Rights, ―Stigmatization of Dalits in access to water and

sanitation in India‖, submission to the Special Rapporteur. 21 WaterAid Ethiopia and Progynist, ―Making the links: mapping the relationships between water,

hygiene and sanitation and HIV/AIDS‖ (2004), p. 5. 22 Maggie Bangser, ―Obstetric fistula and Stigma‖, The Lancet, vol. 367, No. 9509 (2006), p. 535.

E. Threats to privacy and security

39. Stigmatized people frequently face threats to their privacy; they experience people staring at them, in particular when they look physically different from what is considered ―normal‖. They are verbally insulted, harassed or threatened or experience physical abuse and violence, for instance, when attempting to access water and sanitation facilities. Such threats directly affect people‘s access to services and have a detrimental effect on their

health, dignity and livelihoods. In many instances, the perpetrators are not held accountable, but rather enjoy impunity.

40. A report of the United Nations High Commissioner for Human Rights on discriminatory laws and practices and acts of violence against individuals based on their sexual orientation and gender identity has highlighted that homophobic and transphobic violence may be physical or psychological, and that those attacks ―constitute a form of gender-based violence, driven by a desire to punish those seen as defying gender norms‖ (A/HRC/19/41, para. 20). While the human rights concerns are much broader, in relation to water and sanitation specifically, the use of public bathrooms, which are often sex- segregated, has been associated with exclusion, denial of access, verbal harassment, physical abuse and sometimes even the arrest of transgender and intersex individuals. More broadly, they are at risk of exposure, violence and harassment in seeking access to services such as water and sanitation when those are in common areas, or where privacy is unavailable or compromised.

F. Criminalization

41. Stigma often finds its way into legislative and policy frameworks mirroring societal attitudes and prejudices. In many countries, stigmatization is reflected in the criminalization of work-related activities and practices or the lack of legal protection. For instance, the lack of protection creates a climate of impunity, invisibility and silence and violence against sex workers. They are often forced to work in unsafe environments, including in the outskirts of cities, with no access to services.

42. The stigmatization of homeless persons is starkly apparent in their criminalization, for instance through the adoption of local ordinances criminalizing proxy behaviours, that is, common behaviours among homeless people, including public urination and defecation. While such laws are seemingly neutral, they disproportionately affect homeless people, who rely on public places for these activities.23 Homeless people often have limited access to water, toilets and showers, thus the enforcement of such regulations results in them being denied the rights to water and sanitation.

V. Situating stigma in the human rights framework

43. Stigma is a deeply engrained sociocultural phenomenon that not only disadvantages entire population groups, but often results in serious human rights violations. Situating stigma in the human rights framework is essential for identifying the obligations of States and establishing accountability. Stigma has close links to a range of civil, cultural, economic, political and social rights, highlighting the indivisibility and interdependence of all human rights. The human rights standards and principles of human dignity and non- discrimination, the human rights to water and sanitation and other closely related human

23 Report of the Special Rapporteur on extreme poverty and human rights (A/66/265), paras. 33 ff.

rights will be explored in more depth, as they show close links to the way stigma is manifested in relation to water and sanitation.

A. Human dignity

44. Human dignity is the foundation of all human rights. The International Covenants on Human Rights proclaim that the rights enshrined therein derive from the inherent dignity of the human person. Human dignity is an intrinsic and universal quality of the human person. Behaviour and activities that violate human dignity can include activities or statements that ―demean and humiliate individuals or groups because of their origins, status or beliefs‖, as well as negative stereotyping that implies that members of a particular group are inferior.24 Stigma is, by its demeaning and degrading nature, antithetical to the very idea of human dignity. Stigma as a process of devaluation, of making some people ―lesser‖ and others ―greater‖, is inconsistent with human dignity, which is premised on notions of the inherent equality and worthiness of the human person. It undermines human dignity, thereby laying the groundwork for violations of human rights. Human dignity is closely linked to the realization of the human rights to water and sanitation, and to various related rights such as non-discrimination, the right to be free from inhuman or degrading treatment, and the right to privacy.

B. Human rights to water and sanitation

45. The human rights to water and sanitation are guaranteed under international law. They are components of the right to an adequate standard of living guaranteed in article 11, paragraph 1, of the International Covenant on Economic, Social and Cultural Rights, as well as in many other human rights treaties. Moreover, water and sanitation are inextricably linked to a range of other human rights, including the rights to life, to health and to housing. The human rights to water and sanitation have been reaffirmed through explicit recognition by the General Assembly25 and the Human Rights Council.26

46. States are obliged to progressively realize the human rights to water and sanitation, meaning that they must move as expeditiously and effectively as possible towards the goal of full realization. They must undertake deliberate, concrete and targeted steps and must devote the maximum available resources to the realization of human rights.27

47. States must respect, protect and fulfil the human rights to water and sanitation. They must not only refrain from interfering with these human rights, but also protect individuals against interference by private parties. States, for instance, have positive obligations to take appropriate measures to ensure that persons from stigmatized groups are not excluded from access to wells or facilities. The obligation to fulfil does not generally require States to provide services directly, instead States must create an enabling environment for the realization of these rights. However, when people do not have the means to provide for themselves, the State is required to provide access to water and sanitation services, for instance by ensuring that homeless persons have access to public facilities, or that prisons are adequately equipped with sanitation facilities. The measures required to fully realize the

24 Oscar Schachter, ―Human dignity as a normative concept‖, American Journal of International Law,

vol. 77, No. 4 (1983), p. 852. 25 See resolution 64/292. 26 See resolution 15/9. 27 Committee on Economic, Social and Cultural Rights, general comment No. 3 (1990) on the nature of

States parties obligations, paras. 2 and 10.

human rights to water and sanitation reach far beyond ensuring access to services, and include appropriate measures to combat stigma as a cause of human rights violations.

C. Non-discrimination and equality

48. The right to be free from discrimination in the exercise of human rights, including the rights to water and sanitation, is paramount and cross-cutting under international human rights law. Non-discrimination and equality are central to all core international human rights treaties. They include extensive provisions to protect against discrimination and ensure equality, covering in particular racial discrimination, as well as the situation of children, women, and persons with disabilities.

49. Discrimination is defined as constituting ―any distinction, exclusion, restriction or preference or other differential treatment that is directly or indirectly based on the prohibited grounds of discrimination and which has the intention or effect of nullifying or impairing the recognition, enjoyment or exercise, on an equal footing, of Covenant rights‖.28

50. In terms of prohibited grounds of discrimination, the International Covenants on Human Rights list race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status. The term ―other status‖ indicates that these lists are not exhaustive. The treaty bodies have sought to elucidate the term, finding that it encompasses, inter alia, disability, age, sexual orientation and gender identity, health status, place of residence, and economic and social situation.29 These grounds show a significant overlap with groups experiencing stigmatization, highlighting again that stigma often lies at the root of discrimination. Conversely, this relationship also allows for the use of stigma as a marker and for the consideration of groups who experience stigmatization when interpreting the term ―other status‖. While it may already be implicit in the treaty bodies‘ reasoning, this would, for instance, require the recognition of homelessness as a prohibited ground of discrimination.

51. States have an immediate obligation to guarantee non-discrimination in the exercise of the rights to water and sanitation. They must ensure that laws, policies, programmes and other measures are not discriminatory. When deeply engrained, discrimination is intractable—as is often the case where stigma lies at the root of discriminatory action—and temporary special measures may be required to ensure the redistribution of power and resources. 30 Finally, to address discrimination based on stigma as a deeply entrenched societal phenomenon, States must adopt measures to ensure that private actors do not discriminate on prohibited grounds.31

28 Committee on Economic, Social and Cultural Rights, general comment No. 20, para. 7. See also the

International Convention on the Elimination of All Forms of Racial Discrimination, art. 1; Convention on the Elimination of All Forms of Discrimination against Women, art. 1; Convention on the Rights of Persons with Disabilities, art. 2; Human Rights Committee, general comment No. 18 (1989) on discrimination, para. 7.

29 Committee on Economic, Social and Cultural Rights, general comment No. 20, paras. 2 and 15; Committee on the Elimination of Discrimination against Women, general recommendation No. 28 (2010) on the core obligations of States parties under article 2 of the Convention, para. 18. See also Human Rights Committee, communication No. 488/1992, Toonen v. Australia, Views adopted on 31 March 1994.

30 Committee on Economic, Social and Cultural Rights, general comment No. 20, para. 39. 31 Ibid., para. 11.

D. Prohibition of inhuman or degrading treatment

52. Stigma can also be seen to relate to the prohibition of inhuman or degrading treatment, as provided under, inter alia, the International Covenant on Civil and Political Rights (art. 7), and the Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (art. 16). Inhuman or degrading treatment is interpreted as extending beyond acts causing physical pain to include mental suffering. In the case of degrading treatment, the aspect of humiliation plays a greater role even than the severity of the suffering,32 showing close links to the ways in which stigmatization is experienced.

53. Inhuman or degrading treatment can result from acts, but also from omissions, and States bear responsibility for both.33 The Special Rapporteur has emphasized that ―because evacuation of the bowels and bladder is a necessary biological function and because denial of opportunities to do so in a lawful and dignified manner can both compromise human dignity and cause suffering, such denial could, in some cases (for example, where it results from deliberate actions or clear neglect) amount to cruel, inhumane or degrading treatment‖ (A/HRC/18/33/Add.4, para. 58). This may be of particular relevance to prisoners, homeless persons, slum dwellers and others who are unable to access facilities as a result of the stigma they face. The Human Rights Committee has found that the lack of adequate sanitation in prisons can amount to inhuman treatment.34

54. States are also obliged to protect individuals from acts or omissions of third parties. In that regard, the Human Rights Committee explained that ―it is the duty of the State party

to afford everyone protection through legislative and other measures as may be necessary against the acts prohibited by article 7 [of the International Covenant on Civil and Political Rights], whether inflicted by people acting in their official capacity, outside their official capacity or in a private capacity‖.35 This scope of the prohibition of inhuman or degrading treatment has significant implications for the measures States need to take. They need to address stigma that could result in situations amounting to degrading treatment due to the lack of access to adequate sanitation facilities, for example, in private schools or care institutions, or due to the deliberate denial of access to water or sanitation in that sphere. It is not sufficient for States to simply prohibit such treatment and criminalize it;36 they need comprehensive and positive measures to prevent and address it.

E. Right to privacy

55. According to article 17 of the International Covenant on Civil and Political Rights, ―no one shall be subjected to arbitrary or unlawful interference with his privacy, family, home or correspondence, nor to unlawful attacks on his honour and reputation‖. It guarantees the respect for the individual existence and autonomy of the human being.37 The right to privacy includes the right to be different.38 Human rights law awards the same

32 Manfred Nowak, UN Covenant on Civil and Political Rights – CCPR Commentary, 2nd revised ed.

(Kehl am Rhein, Engel, 2005), p. 165 (para. 14). 33 Committee against Torture, general comment No. 2 (2008) on the implementation of article 2 by

States parties, para. 15. 34 See, for example, Human Rights Committee communication No. 619/1995, Deidrick v. Jamaica,

Views adopted on 9 April 1998, para. 9.3. 35 General comment No. 20 (1992) replacing general comment 7 concerning prohibition of torture and

cruel treatment or punishment, para. 2. 36 Ibid., para. 8. 37 Nowak, CCPR Commentary (note 32 above), p. 378. 38 Ibid., p. 379.

protection to the honour and reputation of, for example, homeless people, sex workers or prisoners as to that of any other member of society.

56. For many stigmatized individuals, stigma results in a negative impact on their right to privacy when attempting to meet their water and sanitation needs. For instance, homeless people may be forced to urinate and defecate in public, given the inexistence or lack of maintenance of public facilities. During her mission to Slovenia, the Special Rapporteur met with Roma communities who were forced to defecate in the open and bathe in a stream due to the lack of adequate facilities. When doing so they were reportedly chased by the police (A/HRC/18/33/Add.2, para. 35). In these cases, the State directly interferes with people‘s privacy, not only by chasing them, but also by not allowing their dwellings to be

connected to water supply and sewerage systems due to their alleged ―illegal‖ status. Similar situations can be found in slums all over the world where the alleged ―illegal‖ status of settlements results in people being denied access to facilities that would guarantee their privacy. In South Africa, a case was brought to the court concerning unenclosed toilets built by the municipality, that is, toilets that were erected without the enclosing superstructure that would hide people from view when using them. The Western Cape High Court found, inter alia, a violation of the right to privacy enshrined in article 14 of the South African Constitution.39

57. Article 17 of the International Covenant on Civil and Political Rights goes on to guarantee that ―everyone has the right to the protection of the law against such interference or attacks‖, thus including an explicit guarantee of protection against interference by private parties. This results in a positive obligation of States parties to protect privacy against interference and attacks by others,40 which has been found to be of particular relevance, for instance, in relation to persons deprived of personal liberty, older persons, persons with disabilities or transgendered persons.41 This provision is of enormous significance in the context of combatting stigma. It clearly demonstrates that States‘ obligations reach into the

private sphere. They cannot dismiss stigma as a social phenomenon over which States have no influence. Instead, they have positive obligations that extend into this realm, requiring States, for instance, to take measures that enable women and girls to manage their menstrual hygiene needs in a manner that protects their privacy and dignity.

VI. Identifying appropriate strategies for prevention and response

58. States cannot meet their human rights obligations without addressing stigma. They not only have obligations not to act as stigmatizers, but are also obliged to protect individuals from actions or omissions of third parties. States must protect individuals from human rights abuses committed by private actors, including the media, service providers, community members and family members. To determine what States are required to do to combat stigma, one can build on the due diligence standard developed to define the obligations of States as regards the actions of private parties. It has been widely used in other areas of law, such as violence against women,42 providing a framework of assessment

39 Western Cape High Court, Beja and Others v. Premier of the Western Cape and Others, case

No. 21332/10, judgement of 3 April 2011, para. 150. 40 Nowak, CCPR Commentary (note 32 above), p. 380 41 Ibid. 42 See report of the Special Rapporteur on violence against women, its causes and consequences

(E/CN.4/2006/61); Declaration on the Elimination of Violence against Women, art. 4 (c); Committee

for ascertaining whether human rights obligations are met. It requires States to go beyond enacting legislation, to take positive action to meet their obligations effectively, and to make a legitimate and reasonable effort to prevent and combat stigma.

59. Since stigma is so complex and so deeply engrained in society, permeating different spheres, preventing and combating it requires holistic approaches and systemic solutions:

(a) Stigma must be addressed at different levels, to ensure change at the level of individual behaviours, as well as at the broader social and cultural levels. It is crucial to recognize the extent to which States perpetuate stigma and address this at the institutional and structural levels;

(b) While States are the primary duty bearers under international human rights law, non-State actors also have responsibilities and can be held accountable for human rights abuses. They should be part of any efforts to combat stigma;

(c) Addressing stigma requires working with the stigmatized as well as with the stigmatizers, while recognizing that there is significant overlap. Those who experience stigmatization due to a certain attribute are just as likely as the majority population to stigmatize others;

(d) Strategies need to cover prevention and address existing stigma, as well as provide for redress for the stigmatized and punishment for the perpetrators where stigmatization results in human rights violations.

A. Participation and empowerment

60. Meaningful participation of stigmatized individuals in crafting measures to combat stigma in relation to water and sanitation is absolutely essential. In order to ensure meaningful participation States must guarantee access to information in relevant languages and formats and targeted to different ages and population groups. For example, since stigma relating to some diseases is often reinforced by a lack of scientific information on ways to prevent, treat or transmit diseases, a critical aspect is to run public health campaigns and ensure that all individuals can seek and receive accurate and trustworthy information. Empowerment should be the key strategy, with those experiencing stigma having space to combat prejudices and discrimination.

61. In the context of sex workers, the Durbar Mahila Samanwaya Committee, a grassroots sex workers‘ collective in India, began organizing self-regulatory boards made up of its staff, doctors, advocates, national human rights commissioners, local politicians and officials, and sex workers themselves in a number of red-light districts. Their objectives included mitigating violence against sex workers, but also brought about improvements in access to water and sanitation.43

62. In order to combat stigma effectively, it is essential to address both its external and internalized dimensions. People who are stigmatized often feel embarrassment and shame, so they remain silent and are incapable of combatting stigma working against them. Where stigmatized people lack voice and agency, empowering them to know and claim their rights is crucial. This requires States to ensure access to information on rights and mechanisms to claim them, as well as to information on issues such as menstruation and hygiene. A

on the Elimination of Discrimination against Women, general recommendation No. 19 (1992) on violence against women, para. 9.

43 Anna-Louise Crago, Our Lives Matter: Sex Workers Unite for Health and Rights (New York, Open Society Institute, 2008), pp. 36 ff.

positive self-perception can motivate others to also change their attitudes. Empowering people supports them in confronting, challenging and educating people who stigmatize them, as well as in holding the State and other actors accountable for discrimination and other human rights violations.

63. Networks of stigmatized people have proven to be well-placed to understand the challenges, and often provide vital community support. Many stigmatized groups are well organized, make claims on their rights, and educate society at large and policymakers. In that regard, further fostering such interactions, networks and organizations is critical to combatting stigma.

B. Awareness-raising to break taboos and challenge stereotypes

64. Silence is a major component of stigma. The first step is to speak openly about what seems ―unpleasant‖ or ―unmentionable‖ or deviates from dominant public opinion, and to recognize the stigma attached—be it obstetric fistula, homelessness, intersexuality, menstrual hygiene or another issue. Stigma is often based on ignorance, fears and misconceptions that can be tackled through awareness-raising. The voice of the stigmatized must be amplified, and their space must be broadened to clearly articulate their needs and rights.

65. Probably the greatest challenge in combatting stigma is the fact that it is deeply entrenched in sociocultural norms and attitudes. Tackling it requires raising awareness of stigmatizing practices that are pursued under the umbrella of culture, religion and tradition. The interpretations of culture on which such practices are based are neither immutable nor homogenous and must therefore be challenged, including by questioning the legitimacy of those who perpetuate stigmatizing practices in the name of culture and uncovering the underlying power dynamics (E/CN.4/2006/61, para. 85).

66. Broad-based awareness-raising and advocacy campaigns on various issues are essential to achieve visibility. This can include posters, booklets, radio, television, magazines, websites and other media. The stigma index developed in the context of HIV/AIDS44 is an innovative tool aimed at measuring stigma and using the data for raising awareness, empowering the stigmatized, and advocating for change. In the context of menstrual hygiene, UNICEF Bangladesh aims to contribute to developing better menstrual hygiene in rural areas through the training of community hygiene promoters targeting 30 million rural Bangladeshis.45

67. The attitudes, stereotypes and prejudices that make up stigma must be uncovered and challenged. In that context, article 5 (a) of the Convention on the Elimination of All Forms of Discrimination against Women requires States parties to take all appropriate measures ―to modify the social and cultural patterns of conduct of men and women, with a view to achieving the elimination of prejudices and customary and all other practices which are based on the idea of the inferiority or the superiority of either of the sexes or on stereotyped roles for men and women‖. Similar provisions requiring States to combat stereotypes and prejudices are included in article 8, paragraph 1 (b) of the Convention on the Rights of Persons with Disabilities and article 7 of the International Convention on the Elimination of All Forms of Racial Discrimination. The rationale of these provisions can be

44 The People living with HIV Stigma Index, available from www.stigmaindex.org. 45 UNICEF, ―Bloody secrets: teaching menstrual hygiene‖, UNICEF Bangladesh, issue No. 8 (2007),

p. 12.

transferred to stigmatized groups in general, since prejudices and ideas of inferiority and superiority are central to the formation of stigma.

68. Eliminating stereotypes requires a combination of measures at different levels that reach a range of stakeholders. Any messages aimed at dismantling stigma should be developed by, or at least in consultation with, the stigmatized. It is specifically incumbent upon States to combat stereotyping in State institutions, including local authorities, by sensitizing and training State officials directly involved in the provision or monitoring of water and sanitation services, as well as law enforcement officials and judges. Judicial decisions, legislation and executive statements have an impact on public attitudes and it is therefore crucial to ensure that they do not perpetuate stereotypes and prejudices.

69. Some prejudices develop at an early age and can be inherited from parents and others and must therefore be addressed as early as possible. Schools have an obligation to educate children to act as agents of change, developing tolerant behaviour towards others, encouraging dialogue and interaction and promoting changes that will eventually permeate other spheres.46 Human rights education with a focus on non-discrimination should be part of every school curriculum. Education should be inclusive, accepting students with differences, so that these differences are perceived as ―normal‖ and students develop respect for ―otherness‖. The same holds true for comprehensive sexual education, including on menstruation, in order to provide accurate information and combat silence and stigma, targeting both girls and boys.

C. Legislative, policy and institutional measures

70. Legislation can protect people and enable them to claim their rights, but it can also create barriers and perpetuate stigmatization. States must develop and reform laws and policies to ensure non-discrimination and equality. They must enact protective legislation, and ensure that laws are implemented and enforced. The more explicitly legislation addresses specific instances of discrimination, the more it can contribute to combatting the related stigma. Legislative measures need to be accompanied by other measures that can achieve changes in institutions, practices, patterns and customs.

71. Evaluating existing laws and assessing their potential discriminatory and stigmatizing impact in the water and sanitation domains is equally important. The stigmatization of homeless communities, for instance, is often reinforced through legislation that criminalizes certain proxy behaviours. Such laws do nothing to address the root causes of homelessness and must be replaced by policies that aim at guaranteeing adequate housing to marginalized individuals and families. A report by the United States Interagency Council on Homelessness, based on information gathered at a summit convened by the council and the United States Department of Justice, condemns the criminalization of homelessness and suggests alternatives that are grounded in community engagement and aimed at overcoming barriers to housing by directly working with the homeless. 47 Building on the recognition that criminalization does not provide any real solutions, all levels of government must put into practice effective alternative approaches.

46 UNICEF, Equity in School (note 16 above), pp. 23-25. See also the Convention on the Rights of the

Child, art. 29, para. 1. 47 The United States Interagency Council on Homelessness, Searching out Solutions: Constructive

Alternatives to the Criminalization of Homelessness (2012), pp. 5 and 30-31.

D. Adopting targeted interventions

72. One of the drivers of stigma is irrational assumptions that influence policy design and implementation. States should adopt policies and measures that are based on evidence, rather than on preconceptions. To establish the evidence base, States should undertake a comprehensive study on stigma, understand who is affected, for what reasons, and how stigma manifests itself. This requires both quantitative and qualitative data. Based on this assessment, States must take targeted measures and affirmative action to address groups that experience stigmatization. This will often require devoting greater resources to these groups, for instance through earmarked funds.

73. For example, some Slovenian municipalities have taken measures in response to the lack of access to water and sanitation in many Roma communities. Previously, either ownership or authorized occupation of a home was required to receive municipal services, thus the unauthorized status of a settlement was a barrier to services. The municipalities of Prekmurje region have waived these strict regulations, which has resulted in all but 3 of the 38 Roma settlements gaining access to services.48

E. Adopting technical measures

74. While the focus in combating stigma must be on bringing about societal change and changes in attitude, technical measures are still crucial to ensure accessibility, for instance for persons with disabilities or older persons, as are public health measures to prevent and cure neglected tropical diseases. Sanitation systems should be adjusted to avoid manual sanitation work. The provision of adequate facilities is crucial for menstrual hygiene management, since it is often the lack of a safe and clean space that prevents women and girls from exercising proper hygiene.

75. Water and sanitation interventions are transformative and can be an entry point for broader societal change. They facilitate the realization of other human rights, such as education, health and work. In many instances, water and sanitation interventions prove to be ideal starting points since everyone shares the need for these services, ensuring access brings tangible improvements in people‘s lives, and speaking about water and sanitation can be easier than addressing societal inequalities at large. To capitalize on that opportunity, technical measures need to be accompanied by measures that go beyond building infrastructure.

F. Ensuring access to justice

76. One of the defining tenets of the human rights framework is accountability. States are obliged to put in place judicial and non-judicial accountability mechanisms to redress human rights violations. Mechanisms must be in place to investigate violations and punish the perpetrators. States must not allow impunity. They must provide for redress at the individual level, including restitution, compensation, satisfaction and/or guarantees of non- repetition.49 Mechanisms at the international level, including the universal periodic review and the procedures of the treaty bodies, should be strengthened and applied in the context of human rights violations based on stigma.

48 Catarina de Albuquerque, On the Right Track: Good Practices in Realising the Rights to Water and

Sanitation (Lisbon, 2012), p. 144. 49 Committee on Economic, Social and Cultural Rights, general comment No. 15 (2002) on the right to

water, para. 55.

77. Access to justice must not only be provided for in the law, but be ensured in practice. States should ensure accountability mechanisms that are accessible, affordable, timely and effective.50 Stigmatized individuals are often affected by a range of barriers in accessing the courts and other mechanisms, including physical, economic or linguistic barriers. States should take measures to ensure physical access to buildings, for instance for persons with disabilities (see Convention on the Rights of Persons with Disabilities, art. 13), adopt legal aid schemes, and provide relevant information in local languages, among other relevant measures.

VII. Conclusions and recommendations

78. Stigma plays an insidious role in perpetuating, “justifying” and ultimately creating impunity for human rights violations. It also serves to silence and erase

issues, and exclude individuals and communities from access to water and sanitation,

preventing some people from exercising their civil, cultural, economic, political and

social rights. Most often, stigmatized individuals are the ones whose lives and health

are placed directly in jeopardy by lack of access to water and sanitation.

79. The human rights framework requires States to prioritize the most marginalized, and to ensure their access to information, empowerment and effective

participation. States must identify challenges, duty bearers and solutions through

bottom-up local diagnostics, ensure accountability and tie any measures taken to

substantive human rights standards. This process is as essential in combating stigma

as the substantive parameters it hinges upon. The process of having the conversation,

of including people in the discussion, and finding solutions together, has the potential

to effect shifts in attitudes and behaviours and to lead to lasting and transformative

changes.

80. Only by addressing stigma will States be able to fully realize the human rights to water and sanitation, and ensure non-discrimination or the prohibition of inhuman

and degrading treatment. Comprehensive and holistic measures to prevent, address

and provide for redress in cases of stigma and punish the perpetrators where stigma

results in the violation of human rights are indispensable. States must refrain from

any activities that perpetuate and institutionalize stigma, and must protect individuals

from human rights abuses committed by third parties, including, for example, service

providers, the media, community members and family members, that are rooted in

stigma as a deeply entrenched sociocultural phenomenon. To that extent, States must

act with due diligence. They must go beyond enacting formal legal provisions and take

positive action to meet their obligations effectively and make a legitimate and

reasonable effort to prevent and combat stigma.

81. Stigma must be addressed in its external and internalized dimensions in order to combat it effectively. Information, participation and empowerment must be the

starting point of any measures to combat stigma. Many stigmatized groups are well

organized, make claims on their rights, and educate society at large. States and other

stakeholders should further empower stigmatized groups and individuals to claim

their rights and to confront and challenge stigma and the people who stigmatize them.

All relevant stakeholders, including individuals, communities, families, civil society

organizations, networks of stigmatized groups, the media and donors, among many

others, have responsibilities to combat stigma and should work together.

50 Committee on Economic, Social and Cultural Rights, general comment No. 9 (1998) on the domestic

application of the Covenant, para. 9.

82. In line with the above, the Special Rapporteur offers the following recommendations:

(a) States must tackle the practice of stigmatization in their strategies for

fully realizing the rights to water and sanitation, in the elaboration and

implementation of national plans of action for water and sanitation and in financing

water and sanitation sectors;

(b) In order to better understand this phenomenon, States must undertake a

comprehensive study on stigma, through a widely participatory process, to identify

stigmatized populations, as well as to analyse the drivers of stigma in relation to the

realization of the human rights to water and sanitation. This process should be based

on the experience of people who face stigmatization, giving them space for articulation

and empowering them to claim their human rights;

(c) Such study and its findings should, in particular:

(i) Serve as the basis for the adoption of new legislation and policies or the

revision or amendment of existing legislation and policies which may not

expressly address stigma as one of the key obstacles to exercising the rights to

water and sanitation by individuals or specific population groups. Where

legislation and policies reflect stigmatizing attitudes, institutionalizing and

formalizing stigma, they must be repealed;

(ii) Be widely disseminated, including with the purpose of increasing

awareness about the pervasive impact of stigma in the exercise of the rights to

water and sanitation. States and other stakeholders should adopt broad-based

awareness-raising and advocacy campaigns to ensure the visibility of the

situation of individuals or groups of individuals facing stigma;

(iii) Serve as a basis for challenging stereotypes. Based on the findings, States

should start tackling stigma within the State institutions and adopt public

campaigns. They should focus on school interventions, and target stereotypes

and harmful practices that find a formal “justification” under the umbrella of

culture, law or tradition;

(iv) Serve as the basis for the design of specific policies and programmes, the

allocation of financial and human resources, targeted evidence-based measures

and, where needed, temporary special measures for groups and individuals

facing stigma in relation to the rights to water and sanitation;

(v) Provide guidance in the prioritization of measures taken in the

realization of the human rights to water and sanitation. As stigmatized

individuals are often among the most marginalized and lack access to basic

levels of services, States must target them with priority. States should earmark

resources in the national and municipal budgets for this purpose;

(vi) Be systematically included in periodic reports to treaty body monitoring

mechanisms and to the universal periodic review. Regional human rights

mechanisms should also receive information on a regular basis on stigma

preventing the full enjoyment of the rights to water and sanitation;

(d) National human rights institutions, as well as civil society organizations,

should explicitly address stigma as part of their work, empowering stigmatized

individuals to claim their rights and supporting States to address stigma as part of

their human rights obligations;

(e) States must put in place accountability mechanisms and ensure access to

justice where stigmatization results in human rights violations. Mechanisms must be

in place to investigate violations and punish perpetrators. States must also provide for

redress at the individual level, including restitution, compensation, satisfaction and/or

guarantees of non-repetition. States must guarantee access to justice in practice by

ensuring that mechanisms are accessible, affordable, timely and effective.