World Environmental Health Day, 2014 Commrntary

IN CELEBRATION OF WORLD ENVIRONMENTAL HEALTH DAY 2014 WITH THE THEME: “ADDRESSING ENVIRONMENTAL HEALTH INEQUALITIES” WRITTEN BY Sanitarian ISAH ADAMU, MEMBER, REPRESENTING NIGERIA ON THE COUNCIL OF THE INTERNATIONAL FEDERATION OF ENVIRONMENTAL HEALTH (IFEH)

The World Environmental Health Day (WEHD) was declared for commemoration in 2011 by the International Federation of Environmental Health (IFEH) to bring world attention to the vital role of environmental health profession and services to the improvement of health and well-being of the earth’s inhabitants. The Council of the International Federation of Environmental Health Proclamation of 26^th September 2011 as the foundational World Environmental Health Day which would be commemorated every September by diverse interests with stakes in Environmental Health the world over. In that famous declaration, the IFEH Council considered various fronts from which the noble profession of Environmental Health positively impacts, central to which is the continuing threats to human health posed by pollution, climate change, urbanisation, globalisation  and poverty, among others and the urgent need to adopt a preventive approach so as to maintain and improve the quality of the natural environment, air, water, food, housing and communities in order to reduce the impact of disease and the public health.

There is no gain-saying to stress the need identified by the Federation in addressing the hydra-headed problems associated with climate change, urbanisation and excruciating poverty to which the developing world is seriously exposed especially the sub-Saharan Africa where our dear country is located. The urbanisation occasioned by the Industrial boom of the early 19^th century in Europe set the stage for the complex interaction between Man, his environment and Etiologic Agents of diseases. In the process, diseases hitherto unknown emerged including Plague and Cholera and devastated a sizeable population. In Great Britain, the Cholera outbreak in Northern London was traced to contamination of sources of drinking water with human excrements. The Poor Law Commission which investigated the matter, resulted in the enactment of the Public Health Act in 1848 which introduced a brand new public servant – the Nuisance Inspector responsible for monitoring human endeavours for the purpose of tracking infractions in daily life that could harm human health. This further gave rise to the metamorphosis of the Nuisance Inspector to that of Public Health Officer in 1950s, and finally the Environmental Health Officer in 1972 – spanning over a century. It is important to note that it did not end with just the change of nomenclature but rather encompassed the birth of a profession amidst the array of professions flourishing in Britain and elsewhere in Europe namely the Environmental Health Profession. This resonated to Nigeria where the Sanitary Attendants changed to the Sanitary Inspectors who worked in the then British colonies making the Senior Municipal Sanitary Officer a statutory member of the Legislative Council in 1913 on the amalgamation of both the Southern and Northern Protectorates of Nigeria. Like in Britain the transformation continued until the mid 1980s culminating in the designation, Environmental Health Officer (EHO).

This leads us to ask what Environmental Health means. Simply put, Environmental Health refers to the control of all factors in man’s physical environment which exercise, or may exercise, a deleterious effect on his physical development, health or survival. This for sure is one of the integral parts of Public Health which aims at promoting health and prolonging life of the human being. In Nigeria this noble profession is composed of these components: waste management; food control and hygiene; pest and vector control; environmental health control of housing and sanitation; epidemiological investigation and control; air quality management; occupational health and safety; water resources management and sanitation; noise control; protection of recreational environment; radiation control and health; control of frontiers, air and sea ports and border crossing; pollution control and abatement; educational activities (health promotion and education); promotion and enforcement of environmental health quality standards; collaborative efforts to study the effects of environmental hazards (research); and environmental health impact assessment.(EHIA).

The Federation, in supporting the World Health Organization’s declaration through the World Health Assembly resolution (WHA65.8) which welcomed WHO’s move to facilitate equitable access to health by all through “all-for-equity” and “health-for-all” global actions, therefore decided to focus attention in this respect hence this year’s WEHD theme “ADDRESSING ENVIRONMENTAL HEALTH INEQUALITIES” becomes very relevant most especially in Nigeria where the health sector is prepondently turned to medical circle with the Nation paying dearly for this. The WHO declaration significantly focuses most attention to the Social Determinants of Health as emphasized by the Commission which did the study and prepared its report from which the resolution was arrived at, that health equity was not only achievable but was the right thing to do. These determinants include among several others, Economic ventures; Housing; Transportation; Education; and Infrastructure provisioning. It is evident that each one of these portends a great deal of danger to the health of Nigerians in no small measure since all of them individually or collectively place an individual, a family or indeed a Society on a position in the social gradient. Inadvertently peoples’ standing on the gradient determines how healthy or otherwise they will be such that the poorer the person the lower the position they occupy. That is why Nigeria’s standing on the WHO Country profiles is nothing but discouraging as the gap between the poor and the rich, the educated and non-educated; the urban-based and the rural-based is so wide. These combine to paint a rather gloomy picture of Nigeria’s morbidity and mortality indices.

In considering the health inequalities, IFEH has decided to work with partners ‘to close the gap in inequities within a generation’ by means of improving Environmental Health Services world-wide.

As has been established inequity and inequality lead to poor health. In fairness, the worst kind of inequity is that in regard to health services where in Nigeria like in other settings, have been ‘medicalized’. This is evident in the allocation of resources; prioritization of policies and programmes at every tier of Government whose leadership are mostly concerned with provision of hospital buildings, equipment and consumables as well as hospital-based manpower, leaving out the preventive health aspect. For any addressing of health inequalities to succeed, Governments and societies must have a re-think concerning environmental health which is the vehicle that will improve the Social determinants of health that will in turn impact on the goals of WHO’s resolution 65.8. Over the years Environmental Health has been relegated to the background as a result of neglect of the highest order, little wonder that the country’s morbidity and mortality continue to deteriorate because the basics have been forgotten. The Federal Government that ought to provide leadership is not willing, the State governments that are supposed to guide feel unperturbed while the Local Government which has responsibility to deliver EHS is grounded and moribund.  

In addressing health inequities, the starting point should be addressing environmental health inequalities by accepting the roles assigned to the profession of environmental health by the WHO. When one takes a look at the housing sector for instance, what is glaring is the existence of slums not only in the densely populated settlements but also in high profile or exotic settlements where inhabitants feel they are above board. In fact you technically can detect a lot of issues that warrant declaring some high brow dwellings as posing health risks for their inhabitants. The collapse of building is a common occurrence now – this is mostly attributed to failure of engineering. Agreed, but collapse does not happen overnight, it gives signs like cracks on the walls especially near beams or pillars which degenerate to the point of having the strength of the building compromised. This could easily have been detected by the simple routine Sanitary Inspection of Premises can reveal the smallest potential threats which would be highlighted in the improvement notice to the owner report of which would be forwarded to the town engineering department to enable appropriate actions. Other health hazards include poor ventilation leading to poor air circulation consequence of which is impacting negatively on both out-door and in-door air quality,   as the buildings are erected without recourse to health considerations. Poor ventilation gives rise to moisture which attracts disease vectors like mice and cockroaches and mold which cause and/or aggravate allergic illnesses. In the same manner, finishing materials like paints are improperly used leading to chronic lead poisoning. Due to unavailability of adequate human and material resources, these go unchecked to the extent that buildings remain uninspected for a long period of time and hence resulting in the exacerbation of housing associated health hazards which are silent causes to disease conditions.

The same scenario plays out in the other components of Environmental Health thereby resulting in very poor health indices as reflected by Nigeria’s high morbidity and mortality which are mostly attributable to poor environmental health services organization and management. The conscious and combined efforts of those who think are lords and who know it all in the running of the health services has ensured that environmental health services (EHS) remain the way they were when bequeathed by the colonial masters in the mid 20^th century. This way, their myopia has ensured that environmental health is thus reduced to only everyday sanitation and hygiene when it goes far beyond that. If it were only for sanitation and hygiene, the G-7 nations would not have any needs for it, but quite contrary the world economic super powers like Great Britain and the United States of America do not only maintain robust environmental health structures but also prioritize it among their most important services at all levels of governance.

It is imperative to note that poor leadership of EHS has been the major drawback. At the Federal level, the absence of a full pledged Directorate of EHS in any Federal Ministry has left the profession vulnerable without the much needed leadership thereby leaving it in the wilderness and scattered around the Ministries of Environment and that of Health – resulting in conflict of authority between the two. Despite all entreaties spanning decades the Government is yet to be allowed to do the right thing as every move is blocked by the ‘chosen ones’. This is a form of inequality that remains fatal till today. A sharp comparison is what obtains in our peer that is South Africa which has a Directorate of Environmental Health headed by an EHO in the National Department of Health which is the equivalent of our own Federal Ministry of Health.

It is quite reprehensive that despite having avalanche of well trained Environmental Health Officers who distinguished themselves in their chosen career in the Federal Civil Service, it was not until 2008 that an EHO was promoted into the Directorate Cadre much to the amazement of many. As is known, the Directorate cadre is the circle where policy statements and decisions are moulded for upward submission for approval. This is the policy level where critical thinking, professional articulation and masterly deliveries are supposed to lead via sound professionals well grounded in the job are at the helms of affairs. In place of the rightful bearers of these positions – the EHOs, the job of articulating professional inputs for EHS is left at the mercies of clinicians who by virtue of their training are not equipped to lead EHS. The end result is so glaring for everyone to see. What is more manifest as inequality than this?

The budget of EHS is virtually nonexistent at levels. Where some budget line is provided is solely for municipal solid waste disposal. This is an ugly trend where an important and very crucial sector is maligned and marginalised in terms of funding whereas other health services which are basically clinical get the lion share year-in year-out without justifying the huge sums allocated evident in the ever rising cases of environmental sanitation-related diseases in the country. For the country to make meaningful progress in disease control, preventive health – in all its ramifications must be accorded the necessary attention it desires most especially funding which is the bedrock of any service provisioning.

As Environmental Health flourished in the 1970s the Federal Government in collaboration with the World Health Organisation concluded that it was time that its status needed academic upgrading to suit the changing socio-economic realities in the country. This resulted in the introduction of the Bachelor Degree in Environmental Health programme at the then University of Ife in the early 1980s. To the surprise of Environmental Health family, the Programme was rationalised just after graduating two sets of trainees. The rationalisation, it was much later discovered was achieved as a result of the plot of the self-acclaimed leaders of Nigeria’s health team who touted that there was no need for the then Health Superintendent and Medical laboratory cadre to acquire first degree. For over three decades now Environmental Health Officers’ quest to reach the zenith in the Civil service remains a mere desire as the best they could attain is reaching the bar and retiring at the salary grade level fourteen i.e the Chief Environmental Health Officer cadre.  It is however heart-warming that this situation is gradually becoming history because a few Nigerian Universities with support of the National Universities Commission have reintroduced the programme which the EH community regard as a turning point for the profession such that the educational inequality is eliminated once and for all. In another respect, the profession was most unpardonably sidelined in partaking in the highly regarded Master of Public Health (MPH) programme which was exclusively reserved for physicians when it commenced in some of the first generation Federal Universities in the 1980s. A drama played out when one of us was admitted into the programme in one of the Universities but was refused registration for not qualifying to have been admitted in the first place since he was not a medical doctor. The fellow refused to give up and passionately struggled and succeeded to be registered. It was most ironical that the same unqualified fellow emerged the best student among his ‘super qualified’ physician peers.  We are however glad that this is changing and members of the profession are proving their worth among the diverse professionals who make it into the MPH programmes of non conservative Nigerian Universities.      

Another element of inequality was meted out on EH in the 1990s when the Federal Government granted professional status to every cadre in the health industry by establishing regulatory bodies for them through Military Decrees except the Environmental Health cadre. In explaining it away, the then Minister of Health, a well decorated and celebrated Physician who initiated and ensured the success of the monumental change, upheld that Environmental Health needed not to be recognised as a profession but rather a mere occupation. The fear was if EH was empowered, it would not continue to be the milking cow of the medics. This, the EH family have understood through the fact that, take away Environmental Health Officer, any other health professional is clinic based. And that when his job is robustly done, all other clinic based cadres will have little to do since diseases are prevented thus leading to reduction of clients’ traffic into hospitals for medication.

Fortunately albeit lately, the more-than-fourty-year-struggle for the cadre’s recognition as a profession came to fruition in 2002 when the then President of the Federal Republic of Nigeria, Chief Olusegun Obasanjo assented to the Environmental Health Officers Registration etc Bill into Law giving birth to the Environmental Health Officers Registration Council of Nigeria. There has since then, been tremendous improvement in the services rendered by EHOs nationwide while all necessary policy frameworks are being put in place to ensure that EH regains its pride. Governments at all levels are indicating readiness to returning to the good old days when Environmental Health was the fulcrum of healthcare services.

The IFEH calls on National Governments including that of Nigeria, to make their policies and programmes embrace all the key sectors of society not just the traditional health sector that limits itself to the medical model of public health. It also emphasizes as the WHO Commission has argued, “that in any country the ‘Minister of Health’, who should also be the lead on environmental health issues, and the supporting officials, are critical to achieving the necessary changes. They can champion a ‘social determinants of health’ approach at the highest level of society, they can demonstrate effectiveness through good practice, and they can support other ministries such as the economic, social, housing and environment, as well as planning authorities, in creating policies that promote health equity”.  Furthermore the Commission asserts that “‘achieving health equity within a generation is achievable, it is the right thing to do, and now is the right time to do it”. The Nigerian Government is therefore strongly advised to embrace this clarion call of the WHO in order to make the much needed progress of reducing morbidity and mortality – by improving Environmental Health Services. Little wonder therefore that the slogan of the profession in Nigeria, Sanita Sanitatis; Omni Sanitas – in latin meaning, ‘The health of one man is the health of all’ continues to be relevant any day.